Healthcare Provider Details

I. General information

NPI: 1861936163
Provider Name (Legal Business Name): SERENITY LIVING OF BLAKELY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 BOB WHITE AVE POST OFFICE BOX 144
BLAKELY GA
39823-2630
US

IV. Provider business mailing address

83 BOB WHITE AVE POST OFFICE BOX 144
BLAKELY GA
39823-2630
US

V. Phone/Fax

Practice location:
  • Phone: 229-724-8152
  • Fax:
Mailing address:
  • Phone: 229-724-8152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number049-R-1476
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. MARGARET DAVIS ZACHARY
Title or Position: OWNER/ OFFICE MANAGER
Credential:
Phone: 229-724-8152