=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881161982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENE ADULT DAY CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2018
-----------------------------------------------------
Last Update Date | 10/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3108 EMERSON AVE N
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55411-1366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-558-4384
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2025 3RD AVE N
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55405-1205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-200-9280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ABDULKADIR JAMA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-558-4384
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------