Provider Demographics
NPI:1598106387
Name:SERENITY MANOR ASSISTED LIVING, INC.
Entity Type:Organization
Organization Name:SERENITY MANOR ASSISTED LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TENEMA
Authorized Official - Middle Name:RACHAE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:813-965-3748
Mailing Address - Street 1:322 REGAL PARK DR.
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594
Mailing Address - Country:US
Mailing Address - Phone:813-965-3748
Mailing Address - Fax:
Practice Address - Street 1:322 REGAL PARK DR.
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594
Practice Address - Country:US
Practice Address - Phone:813-965-3748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-10
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL1196310400000X
FLAL10571310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility