=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194338491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY POINT LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2020
-----------------------------------------------------
Last Update Date | 08/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 US HIGHWAY 12 E
-----------------------------------------------------
City | TOWNSEND
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59644-9702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-266-3711
-----------------------------------------------------
Fax | 406-266-4484
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 US HIGHWAY 12 E
-----------------------------------------------------
City | TOWNSEND
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59644-9702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-266-3711
-----------------------------------------------------
Fax | 406-266-4484
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FISCAL AGENT
-----------------------------------------------------
Name | LAURIE DELONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-227-7065
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------