Provider Demographics
NPI:1063810091
Name:RENEW ADDICTION TREATMENT CENTER
Entity type:Organization
Organization Name:RENEW ADDICTION TREATMENT CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:SISCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-653-1505
Mailing Address - Street 1:PO BOX 1285
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-1285
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 VENTERS LN STE 100
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3016
Practice Address - Country:US
Practice Address - Phone:606-653-1505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADAPT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-08
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY740318207RA0401X, 2084A0401X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY740318OtherSTATE FACILITY LICENSE- SPECIAL HEALTH CLINIC