Healthcare Provider Details

I. General information

NPI: 1336588243
Provider Name (Legal Business Name): SERENITY MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2013
Last Update Date: 06/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4018 S RHETT AVE
N CHARLESTON SC
29405-7163
US

IV. Provider business mailing address

PO BOX 21934
CHARLESTON SC
29413-1934
US

V. Phone/Fax

Practice location:
  • Phone: 843-554-0733
  • Fax:
Mailing address:
  • Phone: 843-554-0733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number12184-C07
License Number StateSC

VIII. Authorized Official

Name: MS. HATTIE FIELDS
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 843-554-0733