Provider Demographics
NPI:1962873919
Name:RENVIVA LLC
Entity type:Organization
Organization Name:RENVIVA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:FRITZSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-673-5245
Mailing Address - Street 1:1235 N MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3879
Mailing Address - Country:US
Mailing Address - Phone:513-673-5245
Mailing Address - Fax:866-352-4333
Practice Address - Street 1:1235 N MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3879
Practice Address - Country:US
Practice Address - Phone:513-673-5245
Practice Address - Fax:866-352-4339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-16
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment