Healthcare Provider Details

I. General information

NPI: 1346732773
Provider Name (Legal Business Name): SERENITY CHRISTIAN HOMES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 06/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 PRAIRIE PKWY
WEST FARGO ND
58078-3132
US

IV. Provider business mailing address

1111 PRAIRIE PKWY
WEST FARGO ND
58078-3132
US

V. Phone/Fax

Practice location:
  • Phone: 701-532-0754
  • Fax: 701-532-0839
Mailing address:
  • Phone: 701-532-0754
  • Fax: 701-532-0839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number5801
License Number StateND

VIII. Authorized Official

Name: SEAN BENNETT
Title or Position: ADMINISTRATOR
Credential:
Phone: 218-329-4740