Provider Demographics
NPI:1649847591
Name:PEACEHAVEN BEHAVIORAL CENTER LLC
Entity type:Organization
Organization Name:PEACEHAVEN BEHAVIORAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEACE
Authorized Official - Middle Name:IBEAWUCHI
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:336-991-3491
Mailing Address - Street 1:3916 N POTSDAM AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-7048
Mailing Address - Country:US
Mailing Address - Phone:737-231-0823
Mailing Address - Fax:
Practice Address - Street 1:2175 NW RALEIGH ST STE 110
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2392
Practice Address - Country:US
Practice Address - Phone:737-231-0823
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-09
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)