MEDICARE: SERENITY PLACE ALF, INC.

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	310400000X	Assisted Living Facility	AL10937	FL

General Provider Information

NPI Number	:	1679772370
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY PLACE ALF, INC.

Provider Business Mailing Address
First Line	:	490 BRIGHTON AVE NE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-2023
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	490 BRIGHTON AVE NE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-2023
Country	:	US
Telephone Number	:	321-984-4446
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	BOBSILYN DUNCAN
Credential	:
Telephone Number	:	321-984-4446

Provider Enumeration Date	:	07/12/2007
Last Update Date	:	07/12/2007

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