Healthcare Provider Details

I. General information

NPI: 1992015135
Provider Name (Legal Business Name): CAROL I PEAKE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 11/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5830 WOODROW DR
SYLVANIA OH
43560-1245
US

IV. Provider business mailing address

5830 WOODROW DR
SYLVANIA OH
43560-1245
US

V. Phone/Fax

Practice location:
  • Phone: 419-488-2089
  • Fax:
Mailing address:
  • Phone: 419-488-2089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number177151
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number2127186
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number177151
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code281P00000X
TaxonomyChronic Disease Hospital
License Number1467635664
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number1992015135
License Number StateOH

VIII. Authorized Official

Name: MRS. CAROL I. PEAKE
Title or Position: FNP
Credential: NP-C
Phone: 41948810890