Provider Demographics
NPI:1760863344
Name:SERENE, GAVIN (ATC)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:SERENE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11837 W MONTE LINDO LN
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85373-5004
Mailing Address - Country:US
Mailing Address - Phone:620-877-0358
Mailing Address - Fax:
Practice Address - Street 1:6051 W SWEETWATER AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1112
Practice Address - Country:US
Practice Address - Phone:623-486-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer