Healthcare Provider Details

I. General information

NPI: 1467736561
Provider Name (Legal Business Name): SERENITY MEDICAL CENTER WEST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10765 LANTERN ROAD SUITE 202
FISHERS IN
46038-3597
US

IV. Provider business mailing address

10765 LANTERN ROAD SUITE 202
FISHERS IN
46038-3597
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-4170
  • Fax: 317-621-4182
Mailing address:
  • Phone: 317-621-4170
  • Fax: 317-621-4182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: SYED J KHAN
Title or Position: PARTNER
Credential: MD
Phone: 317-621-4170