1588892848 NPI number — SERENITY HOUSE, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588892848 NPI number — SERENITY HOUSE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERENITY HOUSE, INC
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:
6
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:
1588892848
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2801 W ROOSEVELT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72204-5655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-663-7627
Provider Business Mailing Address Fax Number:
501-663-2859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 W ROOSEVELT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72204-5655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-663-7627
Provider Business Practice Location Address Fax Number:
501-663-2859
Provider Enumeration Date:
06/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GAINES
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
501-663-7627

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D546312 . This is a "ARKANSAS DIVISION OF BEHAVIORAL HEALTH- OADAP" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com