Healthcare Provider Details

I. General information

NPI: 1932404688
Provider Name (Legal Business Name): SERENITY PATH INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W JAMES ST BOX 3
PAYNESVILLE MN
56362-1216
US

IV. Provider business mailing address

117 W JAMES ST BOX 3
PAYNESVILLE MN
56362-1216
US

V. Phone/Fax

Practice location:
  • Phone: 320-243-3379
  • Fax:
Mailing address:
  • Phone: 320-243-3379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number1058815-1-CDT
License Number StateMN

VIII. Authorized Official

Name: MR. WILLIAM MADIGAN
Title or Position: EXECUTIVE DIRECTOR
Credential: MS, LADC, BCCR
Phone: 320-243-3379