Provider Demographics
NPI:1215749718
Name:SERENITY RECUPERATIVE CARE
Entity type:Organization
Organization Name:SERENITY RECUPERATIVE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KHALID
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMATAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-806-4750
Mailing Address - Street 1:360 SHERMAN ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 SHERMAN ST STE 400
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2425
Practice Address - Country:US
Practice Address - Phone:612-806-4750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
No251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No385H00000XRespite Care FacilityRespite Care