Basic Information
| Provider Information | |||||||||
| NPI: | 1386023935 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY CARE SERVICES LLC | ||||||||
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| OtherOrganizationName: | RENOWN HEALTH IMPROVEMENT PROGRAMS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1155 MILL ST # M14 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825262 | ||||||||
| FaxNumber: | 7759825496 | ||||||||
| Practice Location | |||||||||
| Address1: | 10085 DOUBLE R BLVD STE 325 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895214832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825073 | ||||||||
| FaxNumber: | 7759823958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2015 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BECK | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7759826488 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY CARE SERVICES LLC | ||||||||
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| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 133VN1006X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic | 133N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist | 133NN1002X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 163WD0400X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Diabetes Educator | 2083B0002X | Y | 193200000X MULTI-SPECIALTY GROUP |
ID Information
| ID | Type | State | Issuer | Description | 004294 | 01 | NV | AMERICAN DIABETES ASSOCIATION DSME | OTHER |