Healthcare Provider Details

I. General information

NPI: 1972149078
Provider Name (Legal Business Name): SERENITYBEHAVIORALHEALTH.LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2019
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15202 N FLAMENCO DR
PHOENIX AZ
85053-4872
US

IV. Provider business mailing address

15202 N FLAMENCO DR
PHOENIX AZ
85053-4872
US

V. Phone/Fax

Practice location:
  • Phone: 520-302-6217
  • Fax: 602-907-4562
Mailing address:
  • Phone: 520-302-6217
  • Fax: 602-907-4562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: VICTOR NKEM
Title or Position: OWNER
Credential:
Phone: 520-302-6217