Provider Demographics
NPI:1447503974
Name:SERENDIB HEALTHWAYS, INC
Entity type:Organization
Organization Name:SERENDIB HEALTHWAYS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JANESRI
Authorized Official - Middle Name:W
Authorized Official - Last Name:DE SILVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-786-7710
Mailing Address - Street 1:18543 DEVONSHIRE ST
Mailing Address - Street 2:SUITE 435
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-1308
Mailing Address - Country:US
Mailing Address - Phone:818-786-7710
Mailing Address - Fax:818-786-7711
Practice Address - Street 1:14608 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1621
Practice Address - Country:US
Practice Address - Phone:818-786-7710
Practice Address - Fax:818-786-7711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 302R00000X, 363LP2300X
CAA88991208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA88991Medicaid