MEDICARE: SERENITY ANGELS GATHERING PLACE, 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	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1700733755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY ANGELS GATHERING PLACE, LLC

Provider Business Mailing Address
First Line	:	304 WALKER AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23523-1539
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	304 WALKER AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23523-1539
Country	:	US
Telephone Number	:	757-201-1217
Fax Number	:

Authorized Official
Title or Position	:	ADMIN
Name	:	DIAMOND LEIGH
Credential	:
Telephone Number	:	757-201-1217

Provider Enumeration Date	:	03/10/2026
Last Update Date	:	03/10/2026

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