Provider Demographics
NPI:1912494246
Name:SERENITY RESIDENTIAL SERVICES INC
Entity Type:Organization
Organization Name:SERENITY RESIDENTIAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:ASHLEE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-379-8914
Mailing Address - Street 1:2406 UNIVERSITY BLVD W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2002
Mailing Address - Country:US
Mailing Address - Phone:904-379-8914
Mailing Address - Fax:904-800-1465
Practice Address - Street 1:2406 UNIVERSITY BLVD W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2002
Practice Address - Country:US
Practice Address - Phone:904-379-8914
Practice Address - Fax:904-800-1465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X, 320600000X
106S00000X, 320900000X, 385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, ChildGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010423200Medicaid