Healthcare Provider Details

I. General information

NPI: 1104285576
Provider Name (Legal Business Name): KIDSPEACE NATIONAL CENTERS OF NORTH AMERICA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 WEHRLE DR STE 13-14
WILLIAMSVILLE NY
14221-7381
US

IV. Provider business mailing address

4085 INDEPENDENCE DR
SCHNECKSVILLE PA
18078-2574
US

V. Phone/Fax

Practice location:
  • Phone: 716-634-1058
  • Fax: 716-634-1735
Mailing address:
  • Phone: 800-854-3123
  • Fax: 610-799-8318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. MICHALE SLACK
Title or Position: CEO
Credential:
Phone: 610-799-8405