Healthcare Provider Details

I. General information

NPI: 1023459609
Provider Name (Legal Business Name): SERENITY SQUARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 07/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 SURREY ST
LAFAYETTE LA
70501-6142
US

IV. Provider business mailing address

500 SURREY ST
LAFAYETTE LA
70501-6134
US

V. Phone/Fax

Practice location:
  • Phone: 337-266-5892
  • Fax: 337-266-5893
Mailing address:
  • Phone: 337-266-5892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number15006-B
License Number StateLA

VIII. Authorized Official

Name: GWENDOLYN CAILLIER
Title or Position: ADMINISTRATOR
Credential:
Phone: 337-654-5519