Provider Demographics
NPI:1689928319
Name:SERENITY MANOR
Entity Type:Organization
Organization Name:SERENITY MANOR
Other - Org Name:SERENITY HAVEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:ROLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-679-1936
Mailing Address - Street 1:206 MAPLE AVE E
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1311
Mailing Address - Country:US
Mailing Address - Phone:320-679-3580
Mailing Address - Fax:320-679-3579
Practice Address - Street 1:206 MAPLE AVE E
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1311
Practice Address - Country:US
Practice Address - Phone:320-679-3580
Practice Address - Fax:320-679-3579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-02
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1064343324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility