Provider Demographics
NPI:1497811533
Name:PONDELLA SERENITY COURT, LLC
Entity Type:Organization
Organization Name:PONDELLA SERENITY COURT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:MARCIAL / OR YOLETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:OSSELIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-242-0597
Mailing Address - Street 1:1923 NE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-2271
Mailing Address - Country:US
Mailing Address - Phone:239-242-0597
Mailing Address - Fax:239-458-5595
Practice Address - Street 1:1923 NE 6TH ST
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2271
Practice Address - Country:US
Practice Address - Phone:239-242-0597
Practice Address - Fax:239-458-5595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-30
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10725310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility