Provider Demographics
NPI:1275726093
Name:SERENITY SQUARE LLC
Entity Type:Organization
Organization Name:SERENITY SQUARE LLC
Other - Org Name:AGELESS HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:CAILLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-266-5892
Mailing Address - Street 1:1353 SURREY ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-7617
Mailing Address - Country:US
Mailing Address - Phone:337-266-5892
Mailing Address - Fax:
Practice Address - Street 1:1353 SURREY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-7617
Practice Address - Country:US
Practice Address - Phone:337-266-5892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1013871Medicaid