Provider Demographics
NPI:1093494841
Name:SERENITYMED RECOVERY, LLC
Entity Type:Organization
Organization Name:SERENITYMED RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FNP
Authorized Official - Prefix:DR
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:CHANISE
Authorized Official - Last Name:BOLAR
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:678-250-4659
Mailing Address - Street 1:4027 CAITLYN PL
Mailing Address - Street 2:
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30360-3225
Mailing Address - Country:US
Mailing Address - Phone:404-451-7529
Mailing Address - Fax:404-868-5162
Practice Address - Street 1:1954 AIRPORT RD # 670
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-4956
Practice Address - Country:US
Practice Address - Phone:678-250-4659
Practice Address - Fax:404-868-5162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty