Provider Demographics
NPI:1780882019
Name:PEACEFUL HOUSE #3
Entity type:Organization
Organization Name:PEACEFUL HOUSE #3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HATLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-641-7981
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:919-596-4667
Mailing Address - Fax:
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:919-596-4667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-032-348311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805386Medicaid