Provider Demographics
NPI:1952756439
Name:SERENITY VILLA INC
Entity type:Organization
Organization Name:SERENITY VILLA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:REZNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-609-3827
Mailing Address - Street 1:477 PETALUMA AVENUE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472
Mailing Address - Country:US
Mailing Address - Phone:707-827-3685
Mailing Address - Fax:707-861-9160
Practice Address - Street 1:477 PETALUMA AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472
Practice Address - Country:US
Practice Address - Phone:707-827-3685
Practice Address - Fax:707-861-9160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization