Provider Demographics
NPI:1225019011
Name:PEACEHEALTH
Entity Type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:PEACE HARBOR HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:YECNY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-902-6050
Mailing Address - Street 1:400 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-7398
Mailing Address - Country:US
Mailing Address - Phone:541-997-3418
Mailing Address - Fax:541-902-6740
Practice Address - Street 1:2230 KINGWOOD ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-9464
Practice Address - Country:US
Practice Address - Phone:541-997-3418
Practice Address - Fax:541-902-6740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13140711251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR051516Medicaid
OR051516Medicaid