Healthcare Provider Details

I. General information

NPI: 1770030579
Provider Name (Legal Business Name): BEIT SHALOM/HOUSE OF PEACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 PLYMOUTH PL
MIDDLETOWN DE
19709-8313
US

IV. Provider business mailing address

130 PLYMOUTH PL
MIDDLETOWN DE
19709-8313
US

V. Phone/Fax

Practice location:
  • Phone: 678-255-5990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number2016606010
License Number StateDE

VIII. Authorized Official

Name: DR. MILES A RAYNOR
Title or Position: CEO
Credential:
Phone: 678-255-5990