Provider Demographics
NPI:1508126293
Name:PEACE OF MIND ADULT GROUP HOME
Entity Type:Organization
Organization Name:PEACE OF MIND ADULT GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GARY-PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-462-5483
Mailing Address - Street 1:703 BAYBERY LN
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27856-1578
Mailing Address - Country:US
Mailing Address - Phone:252-462-5483
Mailing Address - Fax:252-462-5483
Practice Address - Street 1:703 BAYBERY LN
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:NC
Practice Address - Zip Code:27856-1578
Practice Address - Country:US
Practice Address - Phone:252-462-5483
Practice Address - Fax:252-462-5483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC064131320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities