Provider Demographics
| NPI: | 1821097767 |
|---|---|
| Name: | PEACE RIVER CENTER FOR PERSONAL DEVELOPMENT INC |
| Entity Type: | Organization |
| Organization Name: | PEACE RIVER CENTER FOR PERSONAL DEVELOPMENT INC |
| Other - Org Name: | PEACE RIVER CENTER |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | CREDENTIALING SPECIALIST |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | JO |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | DECK |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | BA, CPC |
| Authorized Official - Phone: | 863-519-0575 |
| Mailing Address - Street 1: | PO BOX 1559 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | BARTOW |
| Mailing Address - State: | FL |
| Mailing Address - Zip Code: | 33831-1559 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 863-519-0575 |
| Mailing Address - Fax: | 863-582-9251 |
| Practice Address - Street 1: | 1239 E MAIN ST |
| Practice Address - Street 2: | |
| Practice Address - City: | BARTOW |
| Practice Address - State: | FL |
| Practice Address - Zip Code: | 33830-5058 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 863-519-0575 |
| Practice Address - Fax: | 863-582-9251 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2005-07-20 |
| Last Update Date: | 2023-12-04 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | Group - Multi-Specialty |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 251B00000X | Agencies | Case Management | Group - Multi-Specialty | |
| No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | |
| No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | |
| No | 261QR1300X | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | Group - Multi-Specialty |
| No | 284300000X | Hospitals | Special Hospital | Group - Multi-Specialty | |
| No | 320800000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | Group - Multi-Specialty | |
| No | 323P00000X | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | Group - Multi-Specialty | |
| No | 343900000X | Transportation Services | Non-emergency Medical Transport (VAN) |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| FL | 060310405 | Medicaid | |
| FL | 060310406 | Medicaid | |
| FL | 060310417 | Medicaid | |
| FL | 060310424 | Medicaid | |
| FL | 761545101 | Medicaid | |
| FL | 060310401 | Medicaid | |
| FL | 060310410 | Medicaid | |
| FL | 060310425 | Medicaid | |
| FL | 060310437 | Medicaid | |
| FL | 060310409 | Medicaid | |
| FL | 060310414 | Medicaid | |
| FL | 060310416 | Medicaid | |
| FL | 060310421 | Medicaid | |
| FL | 060310422 | Medicaid | |
| FL | 060310423 | Medicaid | |
| FL | 060310404 | Medicaid | |
| FL | 060310418 | Medicaid | |
| FL | 060310428 | Medicaid | |
| FL | 060310432 | Medicaid | |
| FL | 060310434 | Medicaid | |
| FL | 060310411 | Medicaid | |
| FL | 060310412 | Medicaid | |
| FL | 060310420 | Medicaid | |
| FL | 060310400 | Medicaid | |
| FL | 060310413 | Medicaid | |
| FL | 060310415 | Medicaid | |
| FL | 060310419 | Medicaid | |
| FL | 060310426 | Medicaid | |
| FL | 060310429 | Medicaid | |
| FL | 060310437 | Medicaid | |
| FL | 060310433 | Medicaid |
