Healthcare Provider Details

I. General information

NPI: 1629696679
Provider Name (Legal Business Name): SERENITY INTERNAL MEDICINE & WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 W 177TH ST # 2D-1
HAZEL CREST IL
60429-2184
US

IV. Provider business mailing address

3330 W 177TH ST # 2D-1
HAZEL CREST IL
60429-2184
US

V. Phone/Fax

Practice location:
  • Phone: 773-234-9662
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTEN TIBBS
Title or Position: PHYSICIAN
Credential: MD
Phone: 773-234-9662