Provider Demographics
NPI:1669348207
Name:LAKE WYLIE SERENITY HOMES LLC
Entity type:Organization
Organization Name:LAKE WYLIE SERENITY HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FAUZIA
Authorized Official - Middle Name:TASLEIMA
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-263-3800
Mailing Address - Street 1:5349 CHARLOTTE HWY
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-8559
Mailing Address - Country:US
Mailing Address - Phone:571-263-3800
Mailing Address - Fax:
Practice Address - Street 1:301 WILSON ST N
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4047
Practice Address - Country:US
Practice Address - Phone:571-263-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE WYLIE SERENITY HOMES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-10-13
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty