Provider Demographics
NPI:1356546113
Name:PEACEFUL HOUSE III
Entity type:Organization
Organization Name:PEACEFUL HOUSE III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CARLEY
Authorized Official - Middle Name:Y
Authorized Official - Last Name:JEGBADAI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:919-790-1953
Mailing Address - Street 1:2724 MARLIN DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-4354
Mailing Address - Country:US
Mailing Address - Phone:919-641-7981
Mailing Address - Fax:919-957-4681
Practice Address - Street 1:2724 MARLIN DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-4354
Practice Address - Country:US
Practice Address - Phone:919-641-7981
Practice Address - Fax:919-957-4681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805386Medicaid