Provider Demographics
NPI:1265505556
Name:SERENITY WELLNESS SPA LLC
Entity Type:Organization
Organization Name:SERENITY WELLNESS SPA LLC
Other - Org Name:PHYSICAL THERAPY AT SERENITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:478-453-0041
Mailing Address - Street 1:107 SPORTSMAN CLUB RD NE
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-8787
Mailing Address - Country:US
Mailing Address - Phone:478-453-0041
Mailing Address - Fax:478-453-0641
Practice Address - Street 1:106 SPORTSMAN CLUB RD NE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-8785
Practice Address - Country:US
Practice Address - Phone:478-453-0041
Practice Address - Fax:478-453-0641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6790225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7008Medicare PIN