Provider Demographics
NPI:1790465664
Name:SERENITY SPACE LLC
Entity Type:Organization
Organization Name:SERENITY SPACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SACAD
Authorized Official - Middle Name:M
Authorized Official - Last Name:GULED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-810-6216
Mailing Address - Street 1:2817 ANTHONY LN S STE 203
Mailing Address - Street 2:
Mailing Address - City:ST ANTHONY
Mailing Address - State:MN
Mailing Address - Zip Code:55418-2491
Mailing Address - Country:US
Mailing Address - Phone:612-810-6216
Mailing Address - Fax:
Practice Address - Street 1:2817 ANTHONY LN S STE 203
Practice Address - Street 2:
Practice Address - City:ST ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55418-2491
Practice Address - Country:US
Practice Address - Phone:612-810-6216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health