Provider Demographics
NPI:1629567573
Name:SERENITY LODGE, INC
Entity Type:Organization
Organization Name:SERENITY LODGE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BALDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-693-5127
Mailing Address - Street 1:PO BOX 2895
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-2895
Mailing Address - Country:US
Mailing Address - Phone:909-693-5127
Mailing Address - Fax:
Practice Address - Street 1:1032 CEDAR LANE
Practice Address - Street 2:
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352
Practice Address - Country:US
Practice Address - Phone:909-693-5127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SERENITY LODGE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA360091AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility