1194014001 NPI number — SERENIY FAMILY CARE HOME

Table of content: (NPI 1194014001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194014001 NPI number — SERENIY FAMILY CARE HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERENIY FAMILY CARE HOME
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194014001
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 377
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRELLS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28444-0377
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-532-4805
Provider Business Mailing Address Fax Number:
910-532-2766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1436 BLAND SCHOOL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARRELLS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28444-7609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-532-4805
Provider Business Practice Location Address Fax Number:
910-532-2766
Provider Enumeration Date:
03/31/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FENNELL
Authorized Official First Name:
ERICA
Authorized Official Middle Name:
TERESA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
910-337-2590

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  FCH-082-017 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3104A0625X , with the licence number: FCH-082-017 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)