MEDICARE: SERENITY SQUARE L.L.C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care
2	320800000X	Mental Illness Community Based Residential Treatment Facility
3	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013439686
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY SQUARE L.L.C

Provider Business Mailing Address
First Line	:	1121 KIELDER CIR
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76134-4514
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 KIELDER CIR
Second Line	:
City	:	FT. WORTH
State	:	TX
Zip	:	76134
Country	:	US
Telephone Number	:	817-877-7466
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	AWNDREA WALKER
Credential	:
Telephone Number	:	817-877-7466

Provider Enumeration Date	:	07/14/2017
Last Update Date	:	06/16/2018

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Directions to “SERENITY SQUARE L.L.C ” Practice Location

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