Provider Demographics
NPI:1598096794
Name:SERENITY WELLNESS LLC
Entity Type:Organization
Organization Name:SERENITY WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:QUIAMBAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-790-0500
Mailing Address - Street 1:PO BOX 6708
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73153-0708
Mailing Address - Country:US
Mailing Address - Phone:405-790-0500
Mailing Address - Fax:405-790-0501
Practice Address - Street 1:3750 W MAIN ST STE AA
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4645
Practice Address - Country:US
Practice Address - Phone:405-790-0500
Practice Address - Fax:405-790-0501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK247082084P0800X
2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200518650AMedicaid
OK200693480AMedicaid
OK100125890AMedicaid
OK200238960AMedicaid
OK200271930AMedicaid