=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730843814
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A PEACEFUL HOME OF LEWISTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2021
-----------------------------------------------------
Last Update Date | 10/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22456 LEWISTON AVE
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-7172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-536-6967
-----------------------------------------------------
Fax | 941-460-4387
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2908 102ND AVE E
-----------------------------------------------------
City | PARRISH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34219-9203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-536-6967
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL BERRY ST JUSTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-536-6967
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------