Provider Demographics
NPI:1720810609
Name:RENAISSANCE HOUSE INC.
Entity type:Organization
Organization Name:RENAISSANCE HOUSE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:FUGATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-439-0464
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-0749
Mailing Address - Country:US
Mailing Address - Phone:734-439-0464
Mailing Address - Fax:
Practice Address - Street 1:601 PEARL ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2616
Practice Address - Country:US
Practice Address - Phone:734-485-1722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness