MEDICARE: SERENITY HOUSE AFCH

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	320700000X	Physical Disabilities Residential Treatment Facility	6906590	FL

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205277407
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY HOUSE AFCH

Provider Business Mailing Address
First Line	:	943 62ND TERRACE S.
Second Line	:
City	:	ST. PETERSBURG
State	:	USA
Zip	:	33705
Country	:	UM
Telephone Number	:	727-906-9405
Fax Number	:	727-906-9405

Provider Business Practice Location Address
First Line	:	943 62ND TER S
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33705-5818
Country	:	US
Telephone Number	:	727-906-9405
Fax Number	:	727-906-9405

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. CAMILLA LEE BRIDGEMAN
Credential	:	PCT
Telephone Number	:	727-906-9405

Provider Enumeration Date	:	07/16/2013
Last Update Date	:	07/16/2013

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Directions to “SERENITY HOUSE AFCH ” Practice Location

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