=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942987946
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACE LEADERS CARE CENTER CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2023
-----------------------------------------------------
Last Update Date | 12/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4801 S UNIVERSITY DR STE 251
-----------------------------------------------------
City | DAVIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33328-3836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-643-3686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4801 S UNIVERSITY DR STE 251
-----------------------------------------------------
City | DAVIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33328-3836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-643-3686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. ALIDA CORTES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-643-3686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------