Provider Demographics
NPI:1043521248
Name:RENNAY ROSE
Entity type:Organization
Organization Name:RENNAY ROSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ITDS
Authorized Official - Prefix:MS
Authorized Official - First Name:RENNAY
Authorized Official - Middle Name:ANN TONJA
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:954-849-1117
Mailing Address - Street 1:203 SW 85TH TER
Mailing Address - Street 2:APT. 306
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-4525
Mailing Address - Country:US
Mailing Address - Phone:954-849-1117
Mailing Address - Fax:
Practice Address - Street 1:203 SW 85TH TER
Practice Address - Street 2:APT. 306
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-4525
Practice Address - Country:US
Practice Address - Phone:954-849-1117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-23
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000512700Medicaid