=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609740760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY HAVEN GROUP HOME LCC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2025
-----------------------------------------------------
Last Update Date | 10/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2400 IVY LN
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55431-2830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-567-2015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20074 67TH AVE
-----------------------------------------------------
City | CORCORAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55340-1018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-980-5325
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DIRECTOR
-----------------------------------------------------
Name | ABDIQANI SHARIF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-980-5325
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------