Provider Demographics
NPI:1710361969
Name:SERENITY FOR LIFE
Entity Type:Organization
Organization Name:SERENITY FOR LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DUEL OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:F
Authorized Official - Last Name:COREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-755-0003
Mailing Address - Street 1:65 PINE AVE
Mailing Address - Street 2:360
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:65 PINE AVE
Practice Address - Street 2:360
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802
Practice Address - Country:US
Practice Address - Phone:626-755-0003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190821AP251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health