MEDICARE: PEACEFUL HEALTH AND RESIDENTIAL SERVICE

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	251E00000X	Home Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235794850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACEFUL HEALTH AND RESIDENTIAL SERVICE

Provider Business Mailing Address
First Line	:	5088 TWO CHIMNEYS CT
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-3264
Country	:	US
Telephone Number	:	703-785-8567
Fax Number	:	703-897-7507

Provider Business Practice Location Address
First Line	:	5088 TWO CHIMNEYS CT
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-3264
Country	:	US
Telephone Number	:	703-785-8567
Fax Number	:	703-897-7507

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	PRINCE GYENIN
Credential	:
Telephone Number	:	703-785-8567

Provider Enumeration Date	:	05/08/2019
Last Update Date	:	05/08/2019

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