Healthcare Provider Details

I. General information

NPI: 1679538433
Provider Name (Legal Business Name): PEACE HAVEN ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 06/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12630 ROTT RD
SAINT LOUIS MO
63127-1214
US

IV. Provider business mailing address

12630 ROTT RD
SAINT LOUIS MO
63127-1214
US

V. Phone/Fax

Practice location:
  • Phone: 314-965-3833
  • Fax: 314-965-5260
Mailing address:
  • Phone: 314-965-3833
  • Fax: 314-965-5260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282J00000X
TaxonomyReligious Nonmedical Health Care Institution
License Number030123
License Number StateMO

VIII. Authorized Official

Name: MRS. ANNE H MCCAULEY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 314-965-3833