Provider Demographics
NPI:1013792506
Name:PURE SERENITY HOMES LLC
Entity Type:Organization
Organization Name:PURE SERENITY HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADON
Authorized Official - Middle Name:A
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-867-3072
Mailing Address - Street 1:1586 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-1359
Mailing Address - Country:US
Mailing Address - Phone:765-867-3072
Mailing Address - Fax:
Practice Address - Street 1:1586 WILSON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-1359
Practice Address - Country:US
Practice Address - Phone:765-437-6431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility