=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972727758
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY HOUSE ASSISTED LIVING, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2007
-----------------------------------------------------
Last Update Date | 04/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5290 E YALE CIR STE 209
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80222-6933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-584-8926
-----------------------------------------------------
Fax | 303-584-9508
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5290 E YALE CIR STE 209
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80222-6933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-584-8926
-----------------------------------------------------
Fax | 303-584-9508
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MICHAEL WARREN ZISLIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-584-8926
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL-0378
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------