Healthcare Provider Details

I. General information

NPI: 1235950080
Provider Name (Legal Business Name): SERENE HEALTH IPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 UNIVERSITY PKWY STE 2000
AIKEN SC
29801-6808
US

IV. Provider business mailing address

410 UNIVERSITY PKWY STE 2000
AIKEN SC
29801-6808
US

V. Phone/Fax

Practice location:
  • Phone: 706-524-7134
  • Fax:
Mailing address:
  • Phone: 706-524-7134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: OSCAR V MEDINA
Title or Position: CEO
Credential:
Phone: 619-259-6999