Provider Demographics
NPI:1336588243
Name:SERENITY MANOR
Entity Type:Organization
Organization Name:SERENITY MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HATTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:843-554-0733
Mailing Address - Street 1:PO BOX 21934
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29413-1934
Mailing Address - Country:US
Mailing Address - Phone:843-554-0733
Mailing Address - Fax:
Practice Address - Street 1:4018 S RHETT AVE
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-7163
Practice Address - Country:US
Practice Address - Phone:843-554-0733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12184-C07320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRC1472Medicaid