Provider Demographics
NPI:1053689091
Name:PEACE, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:PEACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 S MCCALL RD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34224-5049
Mailing Address - Country:US
Mailing Address - Phone:941-548-1148
Mailing Address - Fax:888-736-8693
Practice Address - Street 1:2240 S MCCALL RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224-5049
Practice Address - Country:US
Practice Address - Phone:941-548-1148
Practice Address - Fax:888-736-8693
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA59495225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist