Provider Demographics
NPI:1508758368
Name:GRANTING SERENTIY GROUP LLC
Entity type:Organization
Organization Name:GRANTING SERENTIY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMONN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-528-9889
Mailing Address - Street 1:4410 CLAIBORNE SQ E
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2071
Mailing Address - Country:US
Mailing Address - Phone:804-528-9889
Mailing Address - Fax:
Practice Address - Street 1:4410 CLAIBORNE SQ E
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2071
Practice Address - Country:US
Practice Address - Phone:804-528-9889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-16
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health