Basic Information
| Provider Information | |||||||||
| NPI: | 1740715820 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RENAISSANCE ICU GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6148 | ||||||||
| Address2: | |||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785026148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563628677 | ||||||||
| FaxNumber: | 9563623849 | ||||||||
| Practice Location | |||||||||
| Address1: | 5501 S MCCOLL RD | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785395503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563628677 | ||||||||
| FaxNumber: | 9563623849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2017 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | ADA | ||||||||
| AuthorizedOfficialMiddleName: | X | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9563622171 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.