Healthcare Provider Details

I. General information

NPI: 1265323711
Provider Name (Legal Business Name): PEACE RIVER TCM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 07/14/2025
Certification Date: 07/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 BURNEY RD
OSPREY FL
34229-9444
US

IV. Provider business mailing address

230 BURNEY RD
OSPREY FL
34229-9444
US

V. Phone/Fax

Practice location:
  • Phone: 941-879-6041
  • Fax:
Mailing address:
  • Phone: 941-879-6041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name: MISS KRISTINA LEI GRAHAM
Title or Position: OWNER/ DIRECTOR
Credential: LMT
Phone: 941-879-6041