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General NPI Number Information
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NPI Number | 1215461157
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Entity Type | Organization
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Legal Business Name | ACTIVE SERENITY
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Dates
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Enumeration Date | 04/18/2017
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Last Update Date | 04/18/2017
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Provider Practice Location Address
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Address Line | 9057 NW 57TH ST
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City | TAMARAC
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State | FL
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Zip | 33351-4305
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Country | US
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Telephone | 954-721-1115
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Fax |
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Provider Business Mailing Address
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Address Line | 3799 N PINE ISLAND RD
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City | SUNRISE
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State | FL
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Zip | 33351-6528
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. ANNE IMBERT
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Credential |
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Telephone | 954-655-1067
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL9969
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License Number State | FL
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