Provider Demographics
NPI:1659017416
Name:HOUSE OF SERENITY 1
Entity Type:Organization
Organization Name:HOUSE OF SERENITY 1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMIKO
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-732-5160
Mailing Address - Street 1:2973 N 56TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1528
Mailing Address - Country:US
Mailing Address - Phone:414-732-5160
Mailing Address - Fax:
Practice Address - Street 1:2973 N 56TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1528
Practice Address - Country:US
Practice Address - Phone:414-732-5160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home