Provider Demographics
NPI:1013044247
Name:SERENITY INCORPORATED
Entity Type:Organization
Organization Name:SERENITY INCORPORATED
Other - Org Name:SERENITY PLACE III
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLARICE
Authorized Official - Middle Name:SHYLLON
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:919-771-9173
Mailing Address - Street 1:PO BOX 1583
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27512-1583
Mailing Address - Country:US
Mailing Address - Phone:919-771-9173
Mailing Address - Fax:919-367-0816
Practice Address - Street 1:5005 HOLLYRIDGE DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-3109
Practice Address - Country:US
Practice Address - Phone:919-771-9173
Practice Address - Fax:919-367-0816
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SERENITY INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-27
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-092-443311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804101Medicaid