Provider Demographics
NPI:1891851226
Name:P.E.A.C.E. IN YOUNG LIFE CENTER, INC.
Entity Type:Organization
Organization Name:P.E.A.C.E. IN YOUNG LIFE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARCHELLE
Authorized Official - Middle Name:MITZI
Authorized Official - Last Name:GAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-220-9033
Mailing Address - Street 1:15471 CLOVERLAWN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-1146
Mailing Address - Country:US
Mailing Address - Phone:313-345-3853
Mailing Address - Fax:313-345-4358
Practice Address - Street 1:15471 CLOVERLAWN ST
Practice Address - Street 2:STE 101
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-1146
Practice Address - Country:US
Practice Address - Phone:313-345-3853
Practice Address - Fax:313-345-4358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS38404Medicare UPIN
MIP41700001Medicare PIN