MEDICARE: PEACE RESIDENTIAL CARE HOME, INC

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	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1730758970
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACE RESIDENTIAL CARE HOME, INC

Provider Business Mailing Address
First Line	:	38 S VESPER BEND CIR
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77382-5519
Country	:	US
Telephone Number	:	347-841-5030
Fax Number	:	713-429-0750

Provider Business Practice Location Address
First Line	:	38 S VESPER BEND CIR
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77382-5519
Country	:	US
Telephone Number	:	347-841-5030
Fax Number	:	713-429-0750

Authorized Official
Title or Position	:	CONSULTANT
Name	:	ELLEN CLINTON
Credential	:
Telephone Number	:	817-903-7600

Provider Enumeration Date	:	06/22/2021
Last Update Date	:	07/29/2021

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