Provider Demographics
NPI:1649087768
Name:SERENITY LIVING SOLUTIONS OF BLACKDUCK LLC
Entity type:Organization
Organization Name:SERENITY LIVING SOLUTIONS OF BLACKDUCK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ABDULLAHI
Authorized Official - Middle Name:
Authorized Official - Last Name:OMAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-374-1619
Mailing Address - Street 1:2277 HIGHWAY 36 W STE 300
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3830
Mailing Address - Country:US
Mailing Address - Phone:651-374-1619
Mailing Address - Fax:
Practice Address - Street 1:441 4TH ST NE
Practice Address - Street 2:
Practice Address - City:BLACKDUCK
Practice Address - State:MN
Practice Address - Zip Code:56630-2167
Practice Address - Country:US
Practice Address - Phone:651-374-1619
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility