Provider Demographics
NPI:1164603072
Name:MI SERENITY
Entity Type:Organization
Organization Name:MI SERENITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TEDDY
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:RUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-368-4899
Mailing Address - Street 1:11840 PRIVATE DRIVE 5136
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-5909
Mailing Address - Country:US
Mailing Address - Phone:573-368-4899
Mailing Address - Fax:
Practice Address - Street 1:11840 PRIVATE DRIVE 5136
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-5909
Practice Address - Country:US
Practice Address - Phone:573-368-4899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities