Healthcare Provider Details

I. General information

NPI: 1952189730
Provider Name (Legal Business Name): PEACE ACADEMY CHARTERSCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2023
Last Update Date: 10/20/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1954 CANDLER RD
DECATUR GA
30032-4225
US

IV. Provider business mailing address

1954 CANDLER RD
DECATUR GA
30032-4225
US

V. Phone/Fax

Practice location:
  • Phone: 470-722-0706
  • Fax:
Mailing address:
  • Phone: 470-722-0706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TYESE NICHOLE KING
Title or Position: SCHOOL NURSE
Credential: CCMA
Phone: 470-722-0706