Provider Demographics
NPI:1467107516
Name:SERENITY RECOVERY TREATMENT CENTER
Entity Type:Organization
Organization Name:SERENITY RECOVERY TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURAINE
Authorized Official - Middle Name:MILDRED
Authorized Official - Last Name:FOGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:CCMI, CADC
Authorized Official - Phone:209-831-9767
Mailing Address - Street 1:672 W 11TH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3821
Mailing Address - Country:US
Mailing Address - Phone:209-831-9767
Mailing Address - Fax:
Practice Address - Street 1:672 W 11TH ST STE 305
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3821
Practice Address - Country:US
Practice Address - Phone:209-831-9767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility