Healthcare Provider Details

I. General information

NPI: 1518312404
Provider Name (Legal Business Name): SERENITY RESIDENTIAL HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 N HARVARD AVE
OKLAHOMA CITY OK
73127-4021
US

IV. Provider business mailing address

214 SW 30TH ST
OKLAHOMA CITY OK
73109-6506
US

V. Phone/Fax

Practice location:
  • Phone: 405-946-3341
  • Fax: 405-272-1630
Mailing address:
  • Phone: 405-361-7643
  • Fax: 405-272-1630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. TIMOTHY LEE SHOALS SR.
Title or Position: OWNER
Credential: BS
Phone: 405-361-7643