Provider Demographics
NPI:1972913929
Name:SERENITY THERAPEUTIC MASSAGE
Entity type:Organization
Organization Name:SERENITY THERAPEUTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:LMT
Authorized Official - Phone:863-337-4463
Mailing Address - Street 1:929 GILMORE AVE
Mailing Address - Street 2:APT 34
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-1887
Mailing Address - Country:US
Mailing Address - Phone:863-337-4463
Mailing Address - Fax:
Practice Address - Street 1:11953 S APOPKA VINELAND RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32836-7025
Practice Address - Country:US
Practice Address - Phone:863-337-4463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA75231225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty