Provider Demographics
NPI:1235174335
Name:MOUNTAIN SERENITY, INC.
Entity Type:Organization
Organization Name:MOUNTAIN SERENITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LYNDON
Authorized Official - Last Name:GRIGSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-378-2215
Mailing Address - Street 1:490 WILLIAMS BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-7055
Mailing Address - Country:US
Mailing Address - Phone:606-378-2215
Mailing Address - Fax:606-378-2223
Practice Address - Street 1:490 WILLIAMS BRANCH RD
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-7055
Practice Address - Country:US
Practice Address - Phone:606-378-2215
Practice Address - Fax:606-378-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33000803251B00000X, 251C00000X, 320600000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251B00000XAgenciesCase Management
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services
Not Answered320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY33000803Medicaid