MEDICARE: SERENITY PLACE ALF II

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	310400000X	Assisted Living Facility	11317	FL

General Provider Information

NPI Number	:	1487080891
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY PLACE ALF II

Provider Business Mailing Address
First Line	:	256 BARBAROSSA RD NW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-1809
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	256 BARBAROSSA RD NW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-1809
Country	:	US
Telephone Number	:	321-724-6040
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NICOLE DAVIS
Credential	:
Telephone Number	:	954-804-9785

Provider Enumeration Date	:	09/17/2013
Last Update Date	:	09/17/2013

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