Healthcare Provider Details

I. General information

NPI: 1922340660
Provider Name (Legal Business Name): PEACE IN PEACE OUT PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17217 HEDGEROW PARK RD
CHARLOTTE NC
28277-6662
US

IV. Provider business mailing address

17217 HEDGEROW PARK RD
CHARLOTTE NC
28277-6662
US

V. Phone/Fax

Practice location:
  • Phone: 704-668-8600
  • Fax:
Mailing address:
  • Phone: 704-668-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. ALY FABER
Title or Position: OWNER/MEMBER
Credential: E-RYT, CYT, IYAT
Phone: 704-668-8600