Provider Demographics
NPI:1073787768
Name:LA CASA SERENA
Entity Type:Organization
Organization Name:LA CASA SERENA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HAMBLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-333-0151
Mailing Address - Street 1:324 E 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:EAGAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85925-0609
Mailing Address - Country:US
Mailing Address - Phone:928-333-0151
Mailing Address - Fax:928-333-0154
Practice Address - Street 1:324 EAST 1ST STREET
Practice Address - Street 2:
Practice Address - City:EAGAR
Practice Address - State:AZ
Practice Address - Zip Code:85925-0609
Practice Address - Country:US
Practice Address - Phone:928-333-0151
Practice Address - Fax:928-333-0154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL6954302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization