Provider Demographics
NPI:1043474893
Name:SERENDESTINY ENTERPRISE LLC
Entity type:Organization
Organization Name:SERENDESTINY ENTERPRISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:DIZON
Authorized Official - Last Name:JAZMINES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-922-3922
Mailing Address - Street 1:355 VANILLA GRASS DRIVE
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8331
Mailing Address - Country:US
Mailing Address - Phone:630-922-3922
Mailing Address - Fax:630-922-3923
Practice Address - Street 1:3555 VANILLA GRASS DR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-8331
Practice Address - Country:US
Practice Address - Phone:630-922-3922
Practice Address - Fax:630-922-3923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055400207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055400Medicaid
IL906320Medicare PIN