MEDICARE: SERENITY GOLDEN HOME INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1154254878
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY GOLDEN HOME INC

Provider Business Mailing Address
First Line	:	931 FOREST BAY CT
Second Line	:
City	:	GAMBRILLS
State	:	MD
Zip	:	21054-1603
Country	:	US
Telephone Number	:	443-570-7610
Fax Number	:

Provider Business Practice Location Address
First Line	:	931 FOREST BAY CT
Second Line	:
City	:	GAMBRILLS
State	:	MD
Zip	:	21054-1603
Country	:	US
Telephone Number	:	443-570-7610
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	THIMOTHE KONCHOU
Credential	:
Telephone Number	:	240-305-8645

Provider Enumeration Date	:	06/03/2026
Last Update Date	:	06/03/2026

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