MEDICARE: PEACEFUL GROUP HOME LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1073336194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACEFUL GROUP HOME LLC

Provider Business Mailing Address
First Line	:	1476 BENTREE DR SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-7398
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1476 BENTREE DR SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-7398
Country	:	US
Telephone Number	:	614-368-3657
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	GENTILLE MWIZA
Credential	:
Telephone Number	:	614-368-3657

Provider Enumeration Date	:	11/06/2024
Last Update Date	:	11/06/2024

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