Provider Demographics
NPI:1285949040
Name:SERENITY GARDENS RETIREMENT HOME, INC.
Entity type:Organization
Organization Name:SERENITY GARDENS RETIREMENT HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:BLOSSOM
Authorized Official - Middle Name:
Authorized Official - Last Name:KEATON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-822-4829
Mailing Address - Street 1:6200 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-5914
Mailing Address - Country:US
Mailing Address - Phone:954-983-5174
Mailing Address - Fax:954-964-9892
Practice Address - Street 1:6200 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-5914
Practice Address - Country:US
Practice Address - Phone:954-983-5174
Practice Address - Fax:954-964-9892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001412200Medicaid