Provider Demographics
NPI:1104578889
Name:RENEWED LIGHT LLC
Entity type:Organization
Organization Name:RENEWED LIGHT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DESIMONE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC,LCADC
Authorized Official - Phone:856-508-4925
Mailing Address - Street 1:1225 N BROAD ST STE 1
Mailing Address - Street 2:
Mailing Address - City:WEST DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-1203
Mailing Address - Country:US
Mailing Address - Phone:856-508-4925
Mailing Address - Fax:856-861-1216
Practice Address - Street 1:1225 N BROAD ST STE 1
Practice Address - Street 2:
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-1203
Practice Address - Country:US
Practice Address - Phone:856-508-4925
Practice Address - Fax:856-861-1216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)