MEDICARE: CENTER OF PEACE HEALTH SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1174236749
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER OF PEACE HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	4480 W PEORIA AVE STE 2014480
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85302-2038
Country	:	US
Telephone Number	:	602-400-0231
Fax Number	:

Provider Business Practice Location Address
First Line	:	4480 W PEORIA AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85302-2038
Country	:	US
Telephone Number	:	702-743-4108
Fax Number	:

Authorized Official
Title or Position	:	MANAGER/OWNER
Name	:	CLARISSA BROOKE DEWESE
Credential	:
Telephone Number	:	602-400-0231

Provider Enumeration Date	:	12/28/2022
Last Update Date	:	05/23/2023

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