=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558902916
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY SOBER LIVVING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2019
-----------------------------------------------------
Last Update Date | 10/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4600 REDDIX LN
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71202-5949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-534-9205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 MACON DR
-----------------------------------------------------
City | DELHI
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71232-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-534-9205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS OFFICE MANAGER
-----------------------------------------------------
Name | MR. SAMUEL CHARLES DUNDEE JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 337-534-9205
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------