1518312404 NPI number — SERENITY RESIDENTIAL HOME CARE

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 1518312404 NPI number — SERENITY RESIDENTIAL HOME CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERENITY RESIDENTIAL HOME CARE
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:
1518312404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
214 SW 30TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73109-6506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-361-7643
Provider Business Mailing Address Fax Number:
405-272-1630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1129 N HARVARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73127-4021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-946-3341
Provider Business Practice Location Address Fax Number:
405-272-1630
Provider Enumeration Date:
04/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SHOALS
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
405-361-7643

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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