Provider Demographics
NPI:1790174589
Name:SERENITY SENIOR CARE LLC
Entity Type:Organization
Organization Name:SERENITY SENIOR CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICKETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-390-2290
Mailing Address - Street 1:2680 SE BREVARD AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2680 SE BREVARD AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7203
Practice Address - Country:US
Practice Address - Phone:772-204-2215
Practice Address - Fax:772-905-8048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12595310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility