Provider Demographics
NPI:1629816269
Name:RENEWED LIFE LLC
Entity type:Organization
Organization Name:RENEWED LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:BANKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:AADC, LADAC, LMSW
Authorized Official - Phone:479-970-6454
Mailing Address - Street 1:115 W H ST STE 151
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3426
Mailing Address - Country:US
Mailing Address - Phone:479-970-6454
Mailing Address - Fax:
Practice Address - Street 1:115 W H ST STE 151
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3426
Practice Address - Country:US
Practice Address - Phone:479-970-6454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty