Healthcare Provider Details

I. General information

NPI: 1013439686
Provider Name (Legal Business Name): SERENITY SQUARE L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 KIELDER CIR
FT. WORTH TX
76134
US

IV. Provider business mailing address

1121 KIELDER CIR
FT WORTH TX
76134-4514
US

V. Phone/Fax

Practice location:
  • Phone: 817-877-7466
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: AWNDREA WALKER
Title or Position: CEO
Credential:
Phone: 817-877-7466