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General NPI Number Information
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NPI Number | 1821097767
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Entity Type | Organization
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Legal Business Name | PEACE RIVER CENTER FOR PERSONAL DEVELOPMENT INC
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Dates
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Enumeration Date | 07/20/2005
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Last Update Date | 10/07/2024
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Provider Practice Location Address
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Address Line | 1239 E MAIN ST
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City | BARTOW
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State | FL
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Zip | 33830-5058
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Country | US
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Telephone | 863-519-0575
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Fax | 863-582-9251
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Provider Business Mailing Address
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Address Line | PO BOX 1559
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City | BARTOW
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State | FL
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Zip | 33831-1559
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Country | US
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Telephone | 863-519-0575
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Fax | 863-582-9251
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | JO DECK
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Credential | BA, CPC
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Telephone | 863-519-0575
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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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 | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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Taxonomy #4
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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Taxonomy #5
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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Taxonomy #6
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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Taxonomy #7
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Taxonomy Code | 284300000X
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Taxonomy Name | Special Hospital
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License Number |
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Taxonomy #8
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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Taxonomy #9
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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Taxonomy #10
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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Taxonomy #11
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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