Provider Demographics
NPI:1447686381
Name:SERENITY HOMES-NORTH
Entity type:Organization
Organization Name:SERENITY HOMES-NORTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ABRAHAM,
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSHUA
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:616-361-6571
Mailing Address - Street 1:3109 LAWTON DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-2916
Mailing Address - Country:US
Mailing Address - Phone:616-361-6571
Mailing Address - Fax:616-361-0852
Practice Address - Street 1:830 HAYES ST
Practice Address - Street 2:
Practice Address - City:MARNE
Practice Address - State:MI
Practice Address - Zip Code:49435-9792
Practice Address - Country:US
Practice Address - Phone:616-677-6015
Practice Address - Fax:616-431-5021
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SERENITY HOMES-WEST L.L.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAL700316956310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0097737Medicaid