Provider Demographics
NPI:1033340096
Name:PEACEFUL CARE HOUSE
Entity Type:Organization
Organization Name:PEACEFUL CARE HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CARE PROVIDER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ESTERA
Authorized Official - Middle Name:
Authorized Official - Last Name:BODALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-760-4262
Mailing Address - Street 1:10254 SE ISAAC DR
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-7159
Mailing Address - Country:US
Mailing Address - Phone:503-760-4262
Mailing Address - Fax:503-762-2186
Practice Address - Street 1:10254 SE ISAAC DR
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-7159
Practice Address - Country:US
Practice Address - Phone:503-760-4262
Practice Address - Fax:503-762-2186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0312-513850-0803-P320600000X
OR03125138500803P320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR513850Medicaid