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General NPI Number Information
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NPI Number | 1932404688
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Entity Type | Organization
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Legal Business Name | SERENITY PATH INC.
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Dates
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Enumeration Date | 01/11/2011
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Last Update Date | 01/11/2011
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Provider Practice Location Address
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Address Line | 117 W JAMES ST BOX 3
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City | PAYNESVILLE
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State | MN
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Zip | 56362-1216
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Country | US
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Telephone | 320-243-3379
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Fax |
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Provider Business Mailing Address
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Address Line | 117 W JAMES ST BOX 3
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City | PAYNESVILLE
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State | MN
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Zip | 56362-1216
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Country | US
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Telephone | 320-243-3379
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. WILLIAM MADIGAN
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Credential | MS, LADC, BCCR
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Telephone | 320-243-3379
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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 | 1058815-1-CDT
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License Number State | MN
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