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General NPI Number Information
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NPI Number | 1043474893
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Entity Type | Organization
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Legal Business Name | SERENDESTINY ENTERPRISE LLC
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Dates
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Enumeration Date | 07/10/2008
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Last Update Date | 07/10/2008
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Provider Practice Location Address
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Address Line | 3555 VANILLA GRASS DR
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City | NAPERVILLE
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State | IL
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Zip | 60564-8331
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Country | US
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Telephone | 630-922-3922
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Fax | 630-922-3923
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Provider Business Mailing Address
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Address Line | 355 VANILLA GRASS DRIVE
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City | NAPERVILLE
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State | IL
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Zip | 60564-8331
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Country | US
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Telephone | 630-922-3922
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Fax | 630-922-3923
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LYDIA DIZON JAZMINES
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Credential | MD
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Telephone | 630-922-3922
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207SG0201X
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Taxonomy Name | Clinical Genetics (M.D.) Physician
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License Number | 036055400
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License Number State | IL
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