Healthcare Provider Details

I. General information

NPI: 1013366939
Provider Name (Legal Business Name): SERENITY COMPANION SERVICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2016
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 S MAGNOLIA AVE SUITE 3D
OCALA FL
34471-1178
US

IV. Provider business mailing address

15 FIR TRAIL CRSE
OCALA FL
34472-4220
US

V. Phone/Fax

Practice location:
  • Phone: 352-348-3509
  • Fax: 180-037-2701
Mailing address:
  • Phone: 352-348-3509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number231201
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number231201
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number231201
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number231201
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number231201
License Number StateFL

VIII. Authorized Official

Name: MS. LAVETTE GULLEY
Title or Position: OWNER
Credential:
Phone: 352-348-3509