Provider Demographics
NPI:1154941557
Name:RADIANCE RENEWED
Entity type:Organization
Organization Name:RADIANCE RENEWED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TATANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-689-9104
Mailing Address - Street 1:9445 INDIANAPOLIS BLVD STE 1042
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-2648
Mailing Address - Country:US
Mailing Address - Phone:219-689-9104
Mailing Address - Fax:985-251-2701
Practice Address - Street 1:9445 INDIANAPOLIS BLVD STE 1042
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-2648
Practice Address - Country:US
Practice Address - Phone:219-689-9104
Practice Address - Fax:985-251-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-26
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier