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General NPI Number Information
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NPI Number | 1679802631
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Entity Type | Organization
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Legal Business Name | MY PEACE KEEPER INC
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Dates
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Enumeration Date | 12/21/2009
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Last Update Date | 12/21/2009
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Provider Practice Location Address
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Address Line | 7504 E INDEPENDENCE BLVD STE 101
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City | CHARLOTTE
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State | NC
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Zip | 28227-9407
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Country | US
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Telephone | 704-531-5656
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Fax | 704-531-9711
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Provider Business Mailing Address
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Address Line | 7504 E INDEPENDENCE BLVD STE 101
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City | CHARLOTTE
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State | NC
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Zip | 28227-9407
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Country | US
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Telephone | 704-531-5656
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Fax | 704-531-9711
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. VIRGINIA B POUGH
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Credential | BA
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Telephone | 704-531-5656
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 364SP0810X
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Taxonomy Name | Child & Family Psychiatric/Mental Health Clinical Nurse Specialist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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