MEDICARE: SERENITY HOME, 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	320800000X	Mental Illness Community Based Residential Treatment Facility	122173	NV

General Provider Information

NPI Number	:	1619242971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY HOME, LLC

Provider Business Mailing Address
First Line	:	3111 SKY COUNTRY DR
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89503-1883
Country	:	US
Telephone Number	:	775-787-3239
Fax Number	:

Provider Business Practice Location Address
First Line	:	3111 SKY COUNTRY DR
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89503-1883
Country	:	US
Telephone Number	:	775-787-3239
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. NEDIRA ABDURAHMAN ABUBAKER
Credential	:
Telephone Number	:	775-787-3239

Provider Enumeration Date	:	03/19/2012
Last Update Date	:	03/19/2012

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