Healthcare Provider Details

I. General information

NPI: 1487170759
Provider Name (Legal Business Name): MY PEACE KEEPER II INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3119 SPRING GLEN RD STE 104
JACKSONVILLE FL
32207-5921
US

IV. Provider business mailing address

3119 SPRING GLEN RD STE 104
JACKSONVILLE FL
32207-5921
US

V. Phone/Fax

Practice location:
  • Phone: 980-505-0902
  • Fax: 704-919-5055
Mailing address:
  • Phone: 980-505-0902
  • Fax: 704-919-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: VIRGINIA POUGH
Title or Position: DIRECTOR OF OPERATION
Credential:
Phone: 980-505-0902