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General NPI Number Information
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NPI Number | 1831014166
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Entity Type | Organization
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Legal Business Name | SERENITY LODGE INC
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Dates
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Enumeration Date | 08/13/2026
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Last Update Date | 08/13/2026
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Provider Practice Location Address
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Address Line | 27175 STATE HIGHWAY 189 UNIT A
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City | BLUE JAY
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State | CA
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Zip | 92317
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Country | US
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Telephone | 949-244-2279
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2895
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City | LAKE ARROWHEAD
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State | CA
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Zip | 92352-2895
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Country | US
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Telephone | 949-244-2279
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JESSE LEE KELLERT
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Credential |
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Telephone | 949-244-2279
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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