Healthcare Provider Details

I. General information

NPI: 1114622693
Provider Name (Legal Business Name): SERENE HEALTH IPA MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 BLACKBURN DR STE 523
AUGUSTA GA
30907-8202
US

IV. Provider business mailing address

9265 SKY PARK CT STE 100
SAN DIEGO CA
92123-4375
US

V. Phone/Fax

Practice location:
  • Phone: 844-737-3638
  • Fax: 619-403-9496
Mailing address:
  • Phone: 844-737-3638
  • Fax: 619-403-9496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: OSCAR MEDINA
Title or Position: CEO
Credential:
Phone: 619-259-6999