Provider Demographics
NPI:1346069788
Name:SERENO CLINIC LLC
Entity type:Organization
Organization Name:SERENO CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKSOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-510-0456
Mailing Address - Street 1:10901 CONNECTICUT AVE # 1
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-1645
Mailing Address - Country:US
Mailing Address - Phone:443-510-0456
Mailing Address - Fax:
Practice Address - Street 1:3717 DECATUR AVE STE 3
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2148
Practice Address - Country:US
Practice Address - Phone:443-510-0456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction MedicineGroup - Multi-Specialty