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General NPI Number Information
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NPI Number | 1659164465
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Entity Type | Organization
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Legal Business Name | SERENITY GROUP HOME LLC
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Dates
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Enumeration Date | 05/24/2025
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Last Update Date | 05/24/2025
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Provider Practice Location Address
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Address Line | 1317 CROWN CT
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City | DE PERE
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State | WI
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Zip | 54115-3815
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Country | US
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Telephone | 614-897-6035
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Fax |
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Provider Business Mailing Address
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Address Line | 1317 CROWN CT
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City | DE PERE
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State | WI
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Zip | 54115-3815
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Country | US
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Telephone | 614-897-6035
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Fax | 920-433-6709
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Authorized Official
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Title or Position | OWNER
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Name | KHADRA S HIRSI
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Credential |
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Telephone | 614-897-6035
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #3
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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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