Provider Demographics
NPI:1982881702
Name:PEACEFUL HAVEN RANCH GROUP HOME
Entity Type:Organization
Organization Name:PEACEFUL HAVEN RANCH GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERTO
Authorized Official - Middle Name:E
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-689-0151
Mailing Address - Street 1:12601 STIRLING RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHWEST RANCHES
Mailing Address - State:FL
Mailing Address - Zip Code:33330-3215
Mailing Address - Country:US
Mailing Address - Phone:954-689-0151
Mailing Address - Fax:954-680-9474
Practice Address - Street 1:12601 STIRLING RD
Practice Address - Street 2:
Practice Address - City:SOUTHWEST RANCHES
Practice Address - State:FL
Practice Address - Zip Code:33330-3215
Practice Address - Country:US
Practice Address - Phone:954-689-0151
Practice Address - Fax:954-680-9474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10-1606GH320600000X
FL10-1607GH320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities