Provider Demographics
NPI:1912149626
Name:SERENITY HAVEN ADULT DAY CARE INC
Entity type:Organization
Organization Name:SERENITY HAVEN ADULT DAY CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:NIKKITA
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON- NEEALY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-476-3795
Mailing Address - Street 1:1458 W 123RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-5768
Mailing Address - Country:US
Mailing Address - Phone:773-454-8514
Mailing Address - Fax:773-821-0720
Practice Address - Street 1:1109 E 156TH ST
Practice Address - Street 2:
Practice Address - City:DOLTON
Practice Address - State:IL
Practice Address - Zip Code:60419-2777
Practice Address - Country:US
Practice Address - Phone:708-476-3795
Practice Address - Fax:773-821-0720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-26
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.087417164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty