Provider Demographics
NPI:1316772387
Name:RENEWED1 LLC
Entity type:Organization
Organization Name:RENEWED1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMON
Authorized Official - Middle Name:DENZEL
Authorized Official - Last Name:LESTER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:702-350-1387
Mailing Address - Street 1:401 RYLAND ST STE 200A
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1643
Mailing Address - Country:US
Mailing Address - Phone:702-350-1387
Mailing Address - Fax:
Practice Address - Street 1:401 RYLAND ST STE 200A
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1643
Practice Address - Country:US
Practice Address - Phone:702-350-1387
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-07
Last Update Date:2024-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1194389569Medicaid