Provider Demographics
NPI:1093094310
Name:SERENITY WELLNESS CENTER
Entity Type:Organization
Organization Name:SERENITY WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:QUIAMBAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-790-0500
Mailing Address - Street 1:PO BOX 6708
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73153-0708
Mailing Address - Country:US
Mailing Address - Phone:405-790-0500
Mailing Address - Fax:405-790-0501
Practice Address - Street 1:2227 W LINDSEY ST STE 1550
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069
Practice Address - Country:US
Practice Address - Phone:405-790-0500
Practice Address - Fax:405-790-0501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-04
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK247082084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100125890AMedicaid
OK200518650AMedicaid
OK200693480AMedicaid