Healthcare Provider Details

I. General information

NPI: 1235946617
Provider Name (Legal Business Name): A PLACE OF PEACE 2 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2024
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 GREGORY DR
DELTONA FL
32738-6151
US

IV. Provider business mailing address

1931 N WORTHINGTON DR
DELTONA FL
32738-6143
US

V. Phone/Fax

Practice location:
  • Phone: 386-898-4975
  • Fax: 386-259-9559
Mailing address:
  • Phone: 386-457-3207
  • Fax: 386-259-9559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: SHANTAVIA L COOPER
Title or Position: OWNER
Credential:
Phone: 386-898-4975