=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285949040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY GARDENS RETIREMENT HOME, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2010
-----------------------------------------------------
Last Update Date | 08/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6200 CLEVELAND ST
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-5914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-983-5174
-----------------------------------------------------
Fax | 954-964-9892
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6200 CLEVELAND ST
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-5914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-983-5174
-----------------------------------------------------
Fax | 954-964-9892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/OWNER
-----------------------------------------------------
Name | MISS BLOSSOM KEATON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-822-4829
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------