Healthcare Provider Details

I. General information

NPI: 1679802631
Provider Name (Legal Business Name): MY PEACE KEEPER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2009
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7504 E INDEPENDENCE BLVD STE 101
CHARLOTTE NC
28227-9407
US

IV. Provider business mailing address

7504 E INDEPENDENCE BLVD STE 101
CHARLOTTE NC
28227-9407
US

V. Phone/Fax

Practice location:
  • Phone: 704-531-5656
  • Fax: 704-531-9711
Mailing address:
  • Phone: 704-531-5656
  • Fax: 704-531-9711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SP0810X
TaxonomyChild & Family Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. VIRGINIA B POUGH
Title or Position: EXECUTIVE DIRECTOR
Credential: BA
Phone: 704-531-5656