MEDICARE: PEEK-A-BOO EARLY INTERVENTION SERVICES, 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	251B00000X	Case Management Agency
2	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1821690108
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEEK-A-BOO EARLY INTERVENTION SERVICES, LLC

Provider Business Mailing Address
First Line	:	4975 LACROSS RD STE 101A
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-6523
Country	:	US
Telephone Number	:	843-790-0964
Fax Number	:

Provider Business Practice Location Address
First Line	:	4975 LACROSS RD STE 101A
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-6523
Country	:	US
Telephone Number	:	843-790-0964
Fax Number	:

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	MS. TOMEIKA ARDRELL MARTIN
Credential	:
Telephone Number	:	843-817-7112

Provider Enumeration Date	:	11/12/2020
Last Update Date	:	10/13/2021

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