Provider Demographics
NPI:1891516324
Name:RENEW RESTORE REVISE PSYCHIATRIC SERVICES, LLC
Entity type:Organization
Organization Name:RENEW RESTORE REVISE PSYCHIATRIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHINIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:386-585-2144
Mailing Address - Street 1:PO BOX 45
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-0045
Mailing Address - Country:US
Mailing Address - Phone:386-585-2144
Mailing Address - Fax:
Practice Address - Street 1:7901 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-4305
Practice Address - Country:US
Practice Address - Phone:386-585-2144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty