Provider Demographics
NPI:1952681140
Name:INNER PEACE COMMUNITY SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:INNER PEACE COMMUNITY SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:TENNIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-217-0933
Mailing Address - Street 1:3005 VILLAGE PARK DR STE 204
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-7993
Mailing Address - Country:US
Mailing Address - Phone:919-944-3130
Mailing Address - Fax:919-944-3131
Practice Address - Street 1:3005 VILLAGE PARK DR STE 204
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-7993
Practice Address - Country:US
Practice Address - Phone:919-944-3130
Practice Address - Fax:919-944-3131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0063121041C0700X
SC97421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008780Medicaid
SCGP6439Medicaid
NCC450Medicare PIN