MEDICARE: KEYS TO SERENITY CAREGIVERS LLC

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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1205532140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEYS TO SERENITY CAREGIVERS LLC

Provider Business Mailing Address
First Line	:	8036 MCGARRY TRL
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28214-7649
Country	:	US
Telephone Number	:	704-891-6883
Fax Number	:	980-236-8333

Provider Business Practice Location Address
First Line	:	1546 BERRY BLVD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40215-1955
Country	:	US
Telephone Number	:	704-891-6883
Fax Number	:	980-236-8333

Authorized Official
Title or Position	:	CO-PROVIDER
Name	:	MR. TYRELL FULWOOD
Credential	:
Telephone Number	:	704-891-6883

Provider Enumeration Date	:	02/02/2023
Last Update Date	:	02/02/2023

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