Provider Demographics
NPI:1841182979
Name:RENAISSANCE MEDICAL AESTHETICS
Entity type:Organization
Organization Name:RENAISSANCE MEDICAL AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISSETTE
Authorized Official - Middle Name:I
Authorized Official - Last Name:GUZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-912-8738
Mailing Address - Street 1:11 SANDERSDALE RD # 15
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-2855
Mailing Address - Country:US
Mailing Address - Phone:774-371-4180
Mailing Address - Fax:
Practice Address - Street 1:11 SANDERSDALE RD # 15
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-2855
Practice Address - Country:US
Practice Address - Phone:774-371-4180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty