MEDICARE: MINDFUL PEACE 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	3245S0500X	Children's Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1326745431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL PEACE LLC

Provider Business Mailing Address
First Line	:	1935 N 49TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1735
Country	:	US
Telephone Number	:	262-744-6638
Fax Number	:

Provider Business Practice Location Address
First Line	:	1935 N 49TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1735
Country	:	US
Telephone Number	:	414-212-5723
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICHELLE SIMMONS
Credential	:	SUBSTANCE ABUSE COUN
Telephone Number	:	262-744-6638

Provider Enumeration Date	:	02/09/2023
Last Update Date	:	02/09/2023

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