Basic Information
| Provider Information | |||||||||
| NPI: | 1720243850 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SERENDA | ||||||||
| FirstName: | MARIELLE | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11103 WEST AVE | ||||||||
| Address2: | STE 6 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782131370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105246663 | ||||||||
| FaxNumber: | 2105246587 | ||||||||
| Practice Location | |||||||||
| Address1: | 623 E BOUGHTON RD | ||||||||
| Address2: | STE 120 | ||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604402498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307831514 | ||||||||
| FaxNumber: | 6307830654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2008 | ||||||||
| LastUpdateDate: | 07/29/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 04601029 | IL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.