=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659918266
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACE & EASE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2019
-----------------------------------------------------
Last Update Date | 01/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14362 N FRANK LLOYD WRIGHT BLVD STE B103
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-8881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-912-3105
-----------------------------------------------------
Fax | 480-477-7894
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 12434
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85267-2434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-912-3105
-----------------------------------------------------
Fax | 480-477-7894
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING COMPLIANCE OFFICER
-----------------------------------------------------
Name | REGINA SHAKESPEARE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-554-5633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------