Provider Demographics
NPI:1871461335
Name:RENAISSANCE CDA RE LLC
Entity type:Organization
Organization Name:RENAISSANCE CDA RE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KAMERON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMON
Authorized Official - Suffix:
Authorized Official - Credentials:MEMBER
Authorized Official - Phone:208-376-7298
Mailing Address - Street 1:4334 N BRIGHT ANGEL AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-3611
Mailing Address - Country:US
Mailing Address - Phone:208-376-7298
Mailing Address - Fax:208-377-8310
Practice Address - Street 1:4334 N BRIGHT ANGEL AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-3611
Practice Address - Country:US
Practice Address - Phone:208-376-7298
Practice Address - Fax:208-377-8310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-27
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility