Healthcare Provider Details

I. General information

NPI: 1104572551
Provider Name (Legal Business Name): PEACE RIVER CENTER FOR PERSONAL DEVELOPMENT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 GOLFVIEW AVE
BARTOW FL
33830-6736
US

IV. Provider business mailing address

PO BOX 1559
BARTOW FL
33831-1559
US

V. Phone/Fax

Practice location:
  • Phone: 863-519-0575
  • Fax: 863-582-9251
Mailing address:
  • Phone: 863-519-0575
  • Fax: 863-582-9251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JO DECK
Title or Position: CREDENTIALING SPECIALIST
Credential: BA, CPC
Phone: 863-519-0575