Healthcare Provider Details

I. General information

NPI: 1598344665
Provider Name (Legal Business Name): SERENITY'S BABY SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 S REDBUD AVE
BROKEN ARROW OK
74011-1637
US

IV. Provider business mailing address

4105 S REDBUD AVE
BROKEN ARROW OK
74011-1637
US

V. Phone/Fax

Practice location:
  • Phone: 918-378-9751
  • Fax:
Mailing address:
  • Phone: 918-378-9751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: ARDENIA MONTEILH
Title or Position: CEO/FOUNDER
Credential: RN, LMT
Phone: 918-378-9751