Provider Demographics
NPI:1801416060
Name:RENOVO WELLNESS, LLC
Entity type:Organization
Organization Name:RENOVO WELLNESS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:POPE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:225-256-1634
Mailing Address - Street 1:10771 PERKINS RD STE C
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-1693
Mailing Address - Country:US
Mailing Address - Phone:225-256-1634
Mailing Address - Fax:225-384-5402
Practice Address - Street 1:10771 PERKINS RD STE C
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1693
Practice Address - Country:US
Practice Address - Phone:225-256-1634
Practice Address - Fax:225-384-5402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-17
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty