Provider Demographics
NPI:1730300252
Name:SERENITY INC
Entity Type:Organization
Organization Name:SERENITY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KURT
Authorized Official - Middle Name:D
Authorized Official - Last Name:KASTENDIECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-992-3334
Mailing Address - Street 1:421 SAINT MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7601
Mailing Address - Country:US
Mailing Address - Phone:505-983-9878
Mailing Address - Fax:505-992-0323
Practice Address - Street 1:421 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7601
Practice Address - Country:US
Practice Address - Phone:505-983-9878
Practice Address - Fax:505-992-0323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-52207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH45888Medicare UPIN