MEDICARE: PEACETREE 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1194520791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACETREE LLC

Provider Business Mailing Address
First Line	:	5329 ROANOKE AVE NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-4547
Country	:	US
Telephone Number	:	505-532-0020
Fax Number	:

Provider Business Practice Location Address
First Line	:	5329 ROANOKE AVE NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-4547
Country	:	US
Telephone Number	:	505-532-0020
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LISA MARIA GALLES
Credential	:
Telephone Number	:	505-532-0020

Provider Enumeration Date	:	02/17/2025
Last Update Date	:	02/17/2025

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Directions to “PEACETREE LLC ” Practice Location

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