Provider Demographics
NPI:1992106496
Name:SERENITY PLACE FAMILY CARE GROUP HOME
Entity type:Organization
Organization Name:SERENITY PLACE FAMILY CARE GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED NURSING ASSISTANT
Authorized Official - Prefix:MISS
Authorized Official - First Name:CARMEL
Authorized Official - Middle Name:NATALIE
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:407-914-8731
Mailing Address - Street 1:2011 CARRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-5206
Mailing Address - Country:US
Mailing Address - Phone:407-914-8731
Mailing Address - Fax:
Practice Address - Street 1:2011 CARRINGTON DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-5206
Practice Address - Country:US
Practice Address - Phone:407-914-8731
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010617200Medicaid