Provider Demographics
NPI:1881082238
Name:RENAISSANCE HEALTH AND WELLNESS OF TEXAS, P.A.
Entity type:Organization
Organization Name:RENAISSANCE HEALTH AND WELLNESS OF TEXAS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:479-434-4948
Mailing Address - Street 1:17721 DALLAS PKWY
Mailing Address - Street 2:SUITE 116
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-7343
Mailing Address - Country:US
Mailing Address - Phone:214-378-4700
Mailing Address - Fax:
Practice Address - Street 1:17721 DALLAS PKWY
Practice Address - Street 2:SUITE 116
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-7343
Practice Address - Country:US
Practice Address - Phone:214-378-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ2522208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty