Provider Demographics
NPI:1326753260
Name:SERENITY SENIOR LIVING I, LLC
Entity Type:Organization
Organization Name:SERENITY SENIOR LIVING I, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:214-730-0042
Mailing Address - Street 1:3349 INTERSTATE 30
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-2630
Mailing Address - Country:US
Mailing Address - Phone:214-730-0042
Mailing Address - Fax:
Practice Address - Street 1:1025 CAVERN DR
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75181-4418
Practice Address - Country:US
Practice Address - Phone:972-629-9707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility