Provider Demographics
NPI:1396047239
Name:RENAISSANCE RECOVERY
Entity type:Organization
Organization Name:RENAISSANCE RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:BILLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-551-3534
Mailing Address - Street 1:5250 JOHN R ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-4030
Mailing Address - Country:US
Mailing Address - Phone:313-831-1911
Mailing Address - Fax:313-831-1931
Practice Address - Street 1:5250 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-4030
Practice Address - Country:US
Practice Address - Phone:313-831-1911
Practice Address - Fax:313-831-1931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI823125324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility