Healthcare Provider Details

I. General information

NPI: 1831014166
Provider Name (Legal Business Name): SERENITY LODGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27175 STATE HIGHWAY 189 UNIT A
BLUE JAY CA
92317
US

IV. Provider business mailing address

PO BOX 2895
LAKE ARROWHEAD CA
92352-2895
US

V. Phone/Fax

Practice location:
  • Phone: 949-244-2279
  • Fax:
Mailing address:
  • Phone: 949-244-2279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSE LEE KELLERT
Title or Position: CEO
Credential:
Phone: 949-244-2279