Provider Demographics
NPI:1164752150
Name:SERENITY SPRINGS PERSONAL CARE HOME INC.
Entity Type:Organization
Organization Name:SERENITY SPRINGS PERSONAL CARE HOME INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:MOZELLE
Authorized Official - Last Name:LOVETT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:912-587-3549
Mailing Address - Street 1:4838 MILL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30461-7716
Mailing Address - Country:US
Mailing Address - Phone:912-587-3549
Mailing Address - Fax:912-587-9597
Practice Address - Street 1:4838 MILL CREEK RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30461-7716
Practice Address - Country:US
Practice Address - Phone:912-587-3549
Practice Address - Fax:912-587-9597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016010511320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities