Basic Information
Provider Information | |||||||||
NPI: | 1912516188 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SERENE LIVING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1317 DUPAS ST | ||||||||
Address2: |   | ||||||||
City: | GRETNA | ||||||||
State: | LA | ||||||||
PostalCode: | 700533710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5043191769 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4032 ERATO ST | ||||||||
Address2: |   | ||||||||
City: | NEW ORLEANS | ||||||||
State: | LA | ||||||||
PostalCode: | 701251918 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5043191769 | ||||||||
FaxNumber: | 5043837448 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2020 | ||||||||
LastUpdateDate: | 07/24/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | THOMPSON | ||||||||
AuthorizedOfficialFirstName: | CHERRELL | ||||||||
AuthorizedOfficialMiddleName: | LYNETTE | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5043191769 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHARM D | ||||||||
NPICertificationDate: | 07/24/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X |   |   | N |   | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |   | 323P00000X |   |   | Y |   | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |   |
No ID Information.