Provider Demographics
NPI:1437481116
Name:PEACE PERSONAL CARE HOME
Entity Type:Organization
Organization Name:PEACE PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-482-8215
Mailing Address - Street 1:1352 REGAL HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-3009
Mailing Address - Country:US
Mailing Address - Phone:770-482-8215
Mailing Address - Fax:770-482-8215
Practice Address - Street 1:1352 REGAL HEIGHTS DRIVE
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058
Practice Address - Country:US
Practice Address - Phone:770-482-8215
Practice Address - Fax:770-482-8215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-05
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00157470320600000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities