Provider Demographics
NPI:1770886475
Name:PEACOCK INVESTMENT ENTERPRISES
Entity type:Organization
Organization Name:PEACOCK INVESTMENT ENTERPRISES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-973-9800
Mailing Address - Street 1:458 NW MARION ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-1431
Mailing Address - Country:US
Mailing Address - Phone:850-973-9800
Mailing Address - Fax:850-973-9600
Practice Address - Street 1:458 NW MARION ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-1431
Practice Address - Country:US
Practice Address - Phone:850-973-9800
Practice Address - Fax:850-973-9600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-19
Last Update Date:2010-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10759310400000X
FLAL107953104A0625X
FLAL10295310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142510200Medicaid
FL689952800Medicaid
FL689952801Medicaid