Healthcare Provider Details

I. General information

NPI: 1104934892
Provider Name (Legal Business Name): SERENITY LANE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SERENITY LANE
COBURG OR
97408
US

IV. Provider business mailing address

PO BOX 8549
COBURG OR
97408-1313
US

V. Phone/Fax

Practice location:
  • Phone: 541-284-8605
  • Fax: 541-687-9041
Mailing address:
  • Phone: 541-284-8605
  • Fax: 541-687-9041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: BRIAN CARLIN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 541-284-8617