Healthcare Provider Details

I. General information

NPI: 1033340096
Provider Name (Legal Business Name): PEACEFUL CARE HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 08/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10254 SE ISAAC DR
HAPPY VALLEY OR
97086-7159
US

IV. Provider business mailing address

10254 SE ISAAC DR
HAPPY VALLEY OR
97086-7159
US

V. Phone/Fax

Practice location:
  • Phone: 503-760-4262
  • Fax: 503-762-2186
Mailing address:
  • Phone: 503-760-4262
  • Fax: 503-762-2186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number0312-513850-0803-P
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number03125138500803P
License Number StateOR

VIII. Authorized Official

Name: MISS ESTERA BODALE
Title or Position: CARE PROVIDER
Credential:
Phone: 503-760-4262