Provider Demographics
NPI:1760943575
Name:PEGGY'S PLACE, LLC
Entity Type:Organization
Organization Name:PEGGY'S PLACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIERS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:812-913-4308
Mailing Address - Street 1:1730 AUDUBON DR STE 100
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-3482
Mailing Address - Country:US
Mailing Address - Phone:812-590-2857
Mailing Address - Fax:888-544-7301
Practice Address - Street 1:1730 AUDUBON DR STE 100
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-3482
Practice Address - Country:US
Practice Address - Phone:812-590-2857
Practice Address - Fax:888-544-7301
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEGGY'S PLACE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA249-17-A-0044OtherVETERAN'S AFFAIRS
IN300006752Medicaid