Provider Demographics
NPI:1093175283
Name:PEACEFUL RIVER RESIDENTIAL SERVICES
Entity Type:Organization
Organization Name:PEACEFUL RIVER RESIDENTIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-681-4211
Mailing Address - Street 1:746 RUDGATE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-2929
Mailing Address - Country:US
Mailing Address - Phone:706-571-8859
Mailing Address - Fax:706-243-6357
Practice Address - Street 1:746 RUDGATE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-2929
Practice Address - Country:US
Practice Address - Phone:706-571-8859
Practice Address - Fax:706-243-6357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACLA001207320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003136088AMedicaid