Healthcare Provider Details

I. General information

NPI: 1033480181
Provider Name (Legal Business Name): SERENITY FIELDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2012
Last Update Date: 01/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5447 HAWK EYE DR
BULVERDE TX
78163-2255
US

IV. Provider business mailing address

5447 HAWK EYE DR
BULVERDE TX
78163-2255
US

V. Phone/Fax

Practice location:
  • Phone: 210-392-9520
  • Fax:
Mailing address:
  • Phone: 210-392-9520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: CLINTON R GHOLSON
Title or Position: OWNER
Credential:
Phone: 210-392-9520