Provider Demographics
NPI:1598051302
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:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-538-1572
Mailing Address - Street 1:703 BAYBERRY 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:252-538-1572
Mailing Address - Fax:252-459-2391
Practice Address - Street 1:703 BAYBERRY 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:252-538-1572
Practice Address - Fax:252-459-2391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-064-123320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL-064-123OtherNC DHHS