Provider Demographics
NPI:1649663436
Name:SERENDIPITY MOUNTAIN LODGE
Entity type:Organization
Organization Name:SERENDIPITY MOUNTAIN LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-426-9883
Mailing Address - Street 1:115 TRULL RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-9027
Mailing Address - Country:US
Mailing Address - Phone:719-541-4912
Mailing Address - Fax:
Practice Address - Street 1:41250 ALFORD RD
Practice Address - Street 2:
Practice Address - City:SIMLA
Practice Address - State:CO
Practice Address - Zip Code:80835-9607
Practice Address - Country:US
Practice Address - Phone:719-541-4912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder