Provider Demographics
NPI:1124800891
Name:RENAISSANCE RECOVERY RESOURCES, INC.
Entity type:Organization
Organization Name:RENAISSANCE RECOVERY RESOURCES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CADC II
Authorized Official - Phone:503-304-4358
Mailing Address - Street 1:PO BOX 20674
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97307-0674
Mailing Address - Country:US
Mailing Address - Phone:503-304-4358
Mailing Address - Fax:503-304-4361
Practice Address - Street 1:5775 JEAN RD STE 104
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5311
Practice Address - Country:US
Practice Address - Phone:503-304-4358
Practice Address - Fax:503-304-4361
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RENAISSANCE RECOVERY RESOURCES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-18
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health