Provider Demographics
NPI:1457596678
Name:RENAISSANCE SUPPORTIVE SERVICES INC.
Entity type:Organization
Organization Name:RENAISSANCE SUPPORTIVE SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATRESE
Authorized Official - Middle Name:CURRY
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-786-6486
Mailing Address - Street 1:10213 RISING MIST LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-3006
Mailing Address - Country:US
Mailing Address - Phone:904-786-6486
Mailing Address - Fax:
Practice Address - Street 1:10213 RISING MIST LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-3006
Practice Address - Country:US
Practice Address - Phone:904-786-6486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL690575796251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL690575796Medicaid