MEDICARE: SERENITY COMMUNITY CARE AND BEHAVIORAL HEALTH

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1063794626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY COMMUNITY CARE AND BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	2039 E LAKE MEAD BLVD
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-7135
Country	:	US
Telephone Number	:	702-724-9300
Fax Number	:

Provider Business Practice Location Address
First Line	:	2039 E LAKE MEAD BLVD
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-7135
Country	:	US
Telephone Number	:	702-724-9300
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. EUGENE AHMAD WALLACE
Credential	:
Telephone Number	:	702-326-2529

Provider Enumeration Date	:	09/09/2011
Last Update Date	:	01/26/2012

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