Provider Demographics
NPI:1679951057
Name:SERENITY RECOVERY CLINIC, LLC
Entity Type:Organization
Organization Name:SERENITY RECOVERY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR/COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:K
Authorized Official - Last Name:LUZNICKY
Authorized Official - Suffix:
Authorized Official - Credentials:CSAC
Authorized Official - Phone:414-763-7751
Mailing Address - Street 1:6510 W LAYTON AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4573
Mailing Address - Country:US
Mailing Address - Phone:414-763-7751
Mailing Address - Fax:414-763-7755
Practice Address - Street 1:6510 W LAYTON AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4573
Practice Address - Country:US
Practice Address - Phone:414-763-7751
Practice Address - Fax:414-763-7755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3091251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1609814367Medicaid