Provider Demographics
NPI:1184661100
Name:SERENITY HOSPICE AND HOME
Entity Type:Organization
Organization Name:SERENITY HOSPICE AND HOME
Other - Org Name:SERENITY PALLIATIVE CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LYNNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:KNODLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-732-2499
Mailing Address - Street 1:1658 S IL ROUTE 2
Mailing Address - Street 2:P.O. BOX 462
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061
Mailing Address - Country:US
Mailing Address - Phone:815-732-2499
Mailing Address - Fax:815-732-6077
Practice Address - Street 1:1658 S IL ROUTE 2
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:IL
Practice Address - Zip Code:61061-9514
Practice Address - Country:US
Practice Address - Phone:815-732-2499
Practice Address - Fax:815-732-6077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QH0002X, 207RH0002X
IL2000297251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251G00000XAgenciesHospice Care, Community Based
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid