Healthcare Provider Details

I. General information

NPI: 1215356571
Provider Name (Legal Business Name): SERENITY PAIN RELIEF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2696 LAWRENCEVILLE SUWANEE RD
SUWANEE GA
30024-2535
US

IV. Provider business mailing address

2696 LAWRENCEVILLE SUWANEE RD
SUWANEE GA
30024-2535
US

V. Phone/Fax

Practice location:
  • Phone: 678-376-1300
  • Fax: 678-514-2936
Mailing address:
  • Phone: 678-376-1300
  • Fax: 678-514-2936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number47601
License Number StateGA

VIII. Authorized Official

Name: PHILIP NORTON HENDERSON
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 678-376-1300