=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396922209
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY FAMILY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2008
-----------------------------------------------------
Last Update Date | 08/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2415 S CENTER ST
-----------------------------------------------------
City | HICKORY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28602-5351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-322-8890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2415 S CENTER ST
-----------------------------------------------------
City | HICKORY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28602-7230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-322-8890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUS. MGR.
-----------------------------------------------------
Name | MR. DANNY JEREMIAH FOSTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 828-322-8890
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | FCL-018-028
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------