Provider Demographics
NPI:1578358834
Name:RENEWED IMPRESSIONS OF LIFE LLC
Entity type:Organization
Organization Name:RENEWED IMPRESSIONS OF LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEYVA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-771-5471
Mailing Address - Street 1:6525 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5701
Mailing Address - Country:US
Mailing Address - Phone:909-771-5471
Mailing Address - Fax:
Practice Address - Street 1:6525 ELM AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5701
Practice Address - Country:US
Practice Address - Phone:909-771-5471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage