Provider Demographics
NPI:1205277407
Name:SERENITY HOUSE AFCH
Entity type:Organization
Organization Name:SERENITY HOUSE AFCH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAMILLA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BRIDGEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PCT
Authorized Official - Phone:727-906-9405
Mailing Address - Street 1:943 62ND TERRACE S.
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:USA
Mailing Address - Zip Code:33705
Mailing Address - Country:UM
Mailing Address - Phone:727-906-9405
Mailing Address - Fax:727-906-9405
Practice Address - Street 1:943 62ND TER S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-5818
Practice Address - Country:US
Practice Address - Phone:727-906-9405
Practice Address - Fax:727-906-9405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906590320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5766SPICESMedicaid
FLVACATION51Medicaid