Healthcare Provider Details

I. General information

NPI: 1316492028
Provider Name (Legal Business Name): PEACEDRAPHA HEALTHCARE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 10/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 BUCKLAND ST
CHESAPEAKE VA
23324-3203
US

IV. Provider business mailing address

2004 BUCKLAND ST
CHESAPEAKE VA
23324-3203
US

V. Phone/Fax

Practice location:
  • Phone: 757-222-9690
  • Fax:
Mailing address:
  • Phone: 757-222-9690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2351
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number2351
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2351
License Number StateVA

VIII. Authorized Official

Name: CHIDI EKWUEME
Title or Position: PROGRAM MANAGER
Credential:
Phone: 757-560-6073