MEDICARE: SERENITY CREEK MED SPA

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	207K00000X	Allergy & Immunology Physician

General Provider Information

NPI Number	:	1972911436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY CREEK MED SPA

Provider Business Mailing Address
First Line	:	8900 SHOAL CREEK BLVD
Second Line	:	BUILDING 300-A
City	:	AUSTIN
State	:	TX
Zip	:	78757-6810
Country	:	US
Telephone Number	:	512-375-3858
Fax Number	:	512-375-3865

Provider Business Practice Location Address
First Line	:	8900 SHOAL CREEK BLVD
Second Line	:	BUILDING 300-A
City	:	AUSTIN
State	:	TX
Zip	:	78757-6810
Country	:	US
Telephone Number	:	512-375-3858
Fax Number	:	512-375-3865

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR, RCM DIVISION
Name	:	NATHALIE BLACKSTOCK
Credential	:
Telephone Number	:	512-323-6900

Provider Enumeration Date	:	07/29/2014
Last Update Date	:	07/30/2014

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Directions to “SERENITY CREEK MED SPA ” Practice Location

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