Provider Demographics
NPI:1922340660
Name:PEACE IN PEACE OUT PROGRAM
Entity Type:Organization
Organization Name:PEACE IN PEACE OUT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALY
Authorized Official - Middle Name:
Authorized Official - Last Name:FABER
Authorized Official - Suffix:
Authorized Official - Credentials:E-RYT, CYT, IYAT
Authorized Official - Phone:704-668-8600
Mailing Address - Street 1:17217 HEDGEROW PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-6662
Mailing Address - Country:US
Mailing Address - Phone:704-668-8600
Mailing Address - Fax:
Practice Address - Street 1:17217 HEDGEROW PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6662
Practice Address - Country:US
Practice Address - Phone:704-668-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Multi-Specialty