Provider Demographics
NPI:1194199687
Name:PEACE AND TRANQUILITY RESOURCE CENTER
Entity Type:Organization
Organization Name:PEACE AND TRANQUILITY RESOURCE CENTER
Other - Org Name:PEACE AND TRANQUILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:SCROGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-902-2362
Mailing Address - Street 1:9788 GILESPIE ST STE 424
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-7611
Mailing Address - Country:US
Mailing Address - Phone:702-902-2362
Mailing Address - Fax:
Practice Address - Street 1:9788 GILESPIE ST STE 424
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183
Practice Address - Country:US
Practice Address - Phone:792-902-2362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20151125507320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1154700987Medicaid