Healthcare Provider Details

I. General information

NPI: 1487828182
Provider Name (Legal Business Name): KIDSPEACE NATIONAL CENTERS OF NORTH AMERICA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 SUGARLOAF PKWY STE 120-130
LAWRENCEVILLE GA
30045-9401
US

IV. Provider business mailing address

4085 INDEPENDENCE DR
SCHNECKSVILLE PA
18078-2574
US

V. Phone/Fax

Practice location:
  • Phone: 770-338-0800
  • Fax: 770-338-2219
Mailing address:
  • Phone: 610-799-8543
  • Fax: 610-799-8318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL W. SLACK
Title or Position: VP FOR MARKETING & BUSINESS DEVELOP
Credential:
Phone: 610-799-8405