MEDICARE: SERENITY RESIDENTIAL SERVICESS, 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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1790306934
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY RESIDENTIAL SERVICESS, LLC

Provider Business Mailing Address
First Line	:	6225 WILMINGTON DR
Second Line	:
City	:	BURKE
State	:	VA
Zip	:	22015-3828
Country	:	US
Telephone Number	:	703-718-5444
Fax Number	:

Provider Business Practice Location Address
First Line	:	6225 WILMINGTON DR
Second Line	:
City	:	BURKE
State	:	VA
Zip	:	22015-3828
Country	:	US
Telephone Number	:	703-718-5444
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MARGARET MBESEHA
Credential	:
Telephone Number	:	703-718-5444

Provider Enumeration Date	:	04/28/2020
Last Update Date	:	04/28/2020

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