Provider Demographics
NPI:1659637486
Name:SERENITY RANCH ASSISTED LIVING HOME, INC
Entity Type:Organization
Organization Name:SERENITY RANCH ASSISTED LIVING HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LU ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUELSON
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINASTRATIVE
Authorized Official - Phone:954-533-9184
Mailing Address - Street 1:12475 SW 58TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHWEST RANCHES
Mailing Address - State:FL
Mailing Address - Zip Code:33330-3201
Mailing Address - Country:US
Mailing Address - Phone:954-533-9184
Mailing Address - Fax:954-763-2162
Practice Address - Street 1:12475 SW 58TH ST
Practice Address - Street 2:
Practice Address - City:SOUTHWEST RANCHES
Practice Address - State:FL
Practice Address - Zip Code:33330-3201
Practice Address - Country:US
Practice Address - Phone:954-533-9184
Practice Address - Fax:954-763-2162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11718320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities