1184669145 NPI number — SERENITY OUTPATIENT SERVICES, INC.

Table of content: (NPI 1184669145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184669145 NPI number — SERENITY OUTPATIENT SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERENITY OUTPATIENT SERVICES, 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:
1184669145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4625 ALABAMA ST, STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-566-2000
Provider Business Mailing Address Fax Number:
915-566-2056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4625 ALABAMA ST,
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-566-2000
Provider Business Practice Location Address Fax Number:
915-566-2056
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KRUZICH
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO, OWNER
Authorized Official Telephone Number:
915-566-2000

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  564-A , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com