Provider Demographics
NPI:1427322742
Name:SERENITY SUPPORTED LIVING
Entity type:Organization
Organization Name:SERENITY SUPPORTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAMILLAE'
Authorized Official - Middle Name:TAWNYANETTA
Authorized Official - Last Name:WORTHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-823-0555
Mailing Address - Street 1:216 JOHN AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-4112
Mailing Address - Country:US
Mailing Address - Phone:252-754-9963
Mailing Address - Fax:252-754-9964
Practice Address - Street 1:201 E PITT ST
Practice Address - Street 2:SUITE 208-209
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-5192
Practice Address - Country:US
Practice Address - Phone:252-823-0555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities