Provider Demographics
NPI:1548263791
Name:RENEW HEALTH HOME AND HOME MEDICAL SUPPLY, LLC
Entity type:Organization
Organization Name:RENEW HEALTH HOME AND HOME MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:KYLOCHKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-295-6888
Mailing Address - Street 1:PO BOX 1603
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-1603
Mailing Address - Country:US
Mailing Address - Phone:763-295-6888
Mailing Address - Fax:763-295-6777
Practice Address - Street 1:103 PINE ST
Practice Address - Street 2:STE 103
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8564
Practice Address - Country:US
Practice Address - Phone:763-295-6888
Practice Address - Fax:763-295-6777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5173600001Medicare ID - Type Unspecified