Healthcare Provider Details

I. General information

NPI: 1093094310
Provider Name (Legal Business Name): SERENITY WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 09/28/2024
Certification Date: 09/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 W MAIN ST STE AA
NORMAN OK
73072-4645
US

IV. Provider business mailing address

PO BOX 6708
MOORE OK
73153-0708
US

V. Phone/Fax

Practice location:
  • Phone: 405-790-0500
  • Fax: 405-790-0501
Mailing address:
  • Phone: 405-790-0500
  • Fax: 405-790-0501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number24708
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN QUIAMBAO
Title or Position: PSYCHIATRIST
Credential: MD
Phone: 405-790-0500