1639627524 NPI number — SERENITY HEALING, LLC

Table of content: (NPI 1639627524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639627524 NPI number — SERENITY HEALING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERENITY HEALING, LLC
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:
1639627524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
773 SUMMIT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBOROUGH
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37659-5858
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-218-7851
Provider Business Mailing Address Fax Number:
423-926-4327

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 N BOONE ST
Provider Second Line Business Practice Location Address:
SUITE 17
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-5675
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-926-4327
Provider Business Practice Location Address Fax Number:
423-926-4327
Provider Enumeration Date:
09/20/2016

Additional Information

Authorized Official

Authorized Official Last Name:
CARR
Authorized Official First Name:
JAMYE
Authorized Official Middle Name:
LEIGH
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
423-218-7851

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  2757 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q022731 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com