Healthcare Provider Details

I. General information

NPI: 1962955732
Provider Name (Legal Business Name): MS. VIRGINIA PEEKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIRGINIA PEEKE

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000B S CENTER DR
CLEARLAKE CA
95422-8131
US

IV. Provider business mailing address

5160 QUINELLA CT APT G
GARDEN CITY ID
83714-1483
US

V. Phone/Fax

Practice location:
  • Phone: 707-994-7090
  • Fax:
Mailing address:
  • Phone: 805-123-4567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: