MEDICARE: SERENITY RESIDENTIAL SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	103K00000X	Behavior Analyst	FL
2	106S00000X	Behavior Technician
3	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
4	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care
5	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912494246
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY RESIDENTIAL SERVICES INC

Provider Business Mailing Address
First Line	:	2406 UNIVERSITY BLVD W
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2002
Country	:	US
Telephone Number	:	904-379-8914
Fax Number	:	904-800-1465

Provider Business Practice Location Address
First Line	:	2406 UNIVERSITY BLVD W
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2002
Country	:	US
Telephone Number	:	904-379-8914
Fax Number	:	904-800-1465

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MRS. LAUREN ASHLEE THOMAS
Credential	:
Telephone Number	:	904-379-8914

Provider Enumeration Date	:	04/23/2018
Last Update Date	:	04/23/2018

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Directions to “SERENITY RESIDENTIAL SERVICES INC ” Practice Location

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