MEDICARE: SERENDESTINY ENTERPRISE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207SG0201X	Clinical Genetics (M.D.) Physician	036055400	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043474893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENDESTINY ENTERPRISE LLC

Provider Business Mailing Address
First Line	:	355 VANILLA GRASS DRIVE
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60564-8331
Country	:	US
Telephone Number	:	630-922-3922
Fax Number	:	630-922-3923

Provider Business Practice Location Address
First Line	:	3555 VANILLA GRASS DR
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60564-8331
Country	:	US
Telephone Number	:	630-922-3922
Fax Number	:	630-922-3923

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LYDIA DIZON JAZMINES
Credential	:	MD
Telephone Number	:	630-922-3922

Provider Enumeration Date	:	07/10/2008
Last Update Date	:	07/10/2008

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