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General NPI Number Information
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NPI Number | 1295578151
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Entity Type | Organization
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Legal Business Name | ST CROIX SERENITY HOME LLC
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Dates
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Enumeration Date | 06/17/2024
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Last Update Date | 06/17/2024
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Provider Practice Location Address
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Address Line | 519 8TH ST N # B
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City | HUDSON
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State | WI
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Zip | 54016-1140
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Country | US
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Telephone | 517-505-0174
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Fax |
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Provider Business Mailing Address
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Address Line | 519 8TH ST N # B
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City | HUDSON
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State | WI
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Zip | 54016-1140
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Country | US
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Telephone | 517-505-0174
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MOHAMED A MOHAMED
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Credential |
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Telephone | 517-505-0174
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State |
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