Provider Demographics
NPI:1770019036
Name:PEACE WELLNESS MOBILE UNIT
Entity Type:Organization
Organization Name:PEACE WELLNESS MOBILE UNIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEEPLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-292-7015
Mailing Address - Street 1:502 MULBERRY ST
Mailing Address - Street 2:REAR BLDG
Mailing Address - City:VAIDEN
Mailing Address - State:MS
Mailing Address - Zip Code:39176-9648
Mailing Address - Country:US
Mailing Address - Phone:601-292-7015
Mailing Address - Fax:866-884-6508
Practice Address - Street 1:502 MULBERRY ST
Practice Address - Street 2:REAR BLDG
Practice Address - City:VAIDEN
Practice Address - State:MS
Practice Address - Zip Code:39176-9648
Practice Address - Country:US
Practice Address - Phone:601-292-7015
Practice Address - Fax:866-884-6508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09753895Medicaid