Provider Demographics
NPI:1811442312
Name:SERENITY GROVE, L.L.C.
Entity type:Organization
Organization Name:SERENITY GROVE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:N
Authorized Official - Last Name:VEAL
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:706-389-5157
Mailing Address - Street 1:PO BOX 81485
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30608-1485
Mailing Address - Country:US
Mailing Address - Phone:706-389-5157
Mailing Address - Fax:706-353-1510
Practice Address - Street 1:1021 PARKSIDE CMNS
Practice Address - Street 2:SUITE 104
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-4521
Practice Address - Country:US
Practice Address - Phone:706-389-5157
Practice Address - Fax:706-353-1510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility