Provider Demographics
NPI:1396128757
Name:SERENITY LIVING #2
Entity type:Organization
Organization Name:SERENITY LIVING #2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARICKEYO
Authorized Official - Middle Name:SENTWAN
Authorized Official - Last Name:HUSKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-300-7077
Mailing Address - Street 1:113 SERENITY DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28152-7999
Mailing Address - Country:US
Mailing Address - Phone:704-300-7077
Mailing Address - Fax:704-466-3043
Practice Address - Street 1:113 LESLIE DR
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28152-0757
Practice Address - Country:US
Practice Address - Phone:704-487-5666
Practice Address - Fax:704-466-3043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2015-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-023-046311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home