Provider Demographics
NPI:1487120143
Name:REMEDIES RENEWING LIVES
Entity type:Organization
Organization Name:REMEDIES RENEWING LIVES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF MARKETING/FUND DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BRANNING
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LCPC, CADC,
Authorized Official - Phone:815-966-1285
Mailing Address - Street 1:220 EASTON PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2203
Mailing Address - Country:US
Mailing Address - Phone:815-966-1285
Mailing Address - Fax:815-962-7895
Practice Address - Street 1:1908 PIERCE CT
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-1742
Practice Address - Country:US
Practice Address - Phone:815-547-4502
Practice Address - Fax:815-544-0391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1720259401Medicaid