MEDICARE: SERENITY SAFE HAVEN OUTPATIENT CLINIC

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	SP011319	PA

General Provider Information

NPI Number	:	1942605415
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY SAFE HAVEN OUTPATIENT CLINIC

Provider Business Mailing Address
First Line	:	93 OLD YORK RD STE 1-526
Second Line	:
City	:	JENKINTOWN
State	:	PA
Zip	:	19046-3925
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8410 BUSTLETON AVE STE 2
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-1924
Country	:	US
Telephone Number	:	267-808-8810
Fax Number	:

Authorized Official
Title or Position	:	CO-FOUNDER
Name	:	TAHIRA S DOCKERY
Credential	:	CRNP
Telephone Number	:	267-808-8810

Provider Enumeration Date	:	10/27/2014
Last Update Date	:	10/27/2014

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