Provider Demographics
NPI:1518312404
Name:SERENITY RESIDENTIAL HOME CARE
Entity Type:Organization
Organization Name:SERENITY RESIDENTIAL HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SHOALS
Authorized Official - Suffix:SR
Authorized Official - Credentials:BS
Authorized Official - Phone:405-361-7643
Mailing Address - Street 1:214 SW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-6506
Mailing Address - Country:US
Mailing Address - Phone:405-361-7643
Mailing Address - Fax:405-272-1630
Practice Address - Street 1:1129 N HARVARD AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-4021
Practice Address - Country:US
Practice Address - Phone:405-946-3341
Practice Address - Fax:405-272-1630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home