Healthcare Provider Details

I. General information

NPI: 1255606570
Provider Name (Legal Business Name): PEACE ON EARTH LL ASSISTED LIVING FACILITY,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 SW 14TH CT
POMPANO BEACH FL
33060-8620
US

IV. Provider business mailing address

470 SW 14TH CT
POMPANO BEACH FL
33060-8620
US

V. Phone/Fax

Practice location:
  • Phone: 954-781-4954
  • Fax: 954-227-4657
Mailing address:
  • Phone: 954-781-4954
  • Fax: 954-227-4657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number11315
License Number StateFL

VIII. Authorized Official

Name: MS. CHRISTINE CYNTHIA ROBERTS
Title or Position: OWNER
Credential: ADMINISTRATIVE
Phone: 954-796-9912