=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740826452
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACE HOMECARE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2019
-----------------------------------------------------
Last Update Date | 11/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5127 53RD AVE N
-----------------------------------------------------
City | CRYSTAL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55429-3227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-414-1849
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5127 53RD AVE N
-----------------------------------------------------
City | CRYSTAL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55429-3227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-414-1849
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ ADMINISTRATOR
-----------------------------------------------------
Name | PEACE KIBAARA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-414-1849
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------