Provider Demographics
NPI:1730865197
Name:RENOVIS CHOICE COMPANY
Entity type:Organization
Organization Name:RENOVIS CHOICE COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:MR
Authorized Official - First Name:OLISAELOKA
Authorized Official - Middle Name:
Authorized Official - Last Name:DALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-470-7318
Mailing Address - Street 1:19785 W 12 MILE RD STE 568
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2584
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25433 SAINT JAMES
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-1287
Practice Address - Country:US
Practice Address - Phone:248-470-7318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty