Provider Demographics
NPI:1194908400
Name:SERENITY HOUSE ADULT DAY HEALTH SERVICES, INC.
Entity type:Organization
Organization Name:SERENITY HOUSE ADULT DAY HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-833-4166
Mailing Address - Street 1:POST OFFICE BOX 1334
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601
Mailing Address - Country:US
Mailing Address - Phone:601-833-4166
Mailing Address - Fax:
Practice Address - Street 1:511 N. CHURCH STREET
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2709
Practice Address - Country:US
Practice Address - Phone:601-833-4166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS887539251J00000X, 261QA0600X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251J00000XAgenciesNursing Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03680547Medicaid