MEDICARE: CITY OF PEACE, INC

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
2	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1467725614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF PEACE, INC

Provider Business Mailing Address
First Line	:	1601 WILLISTON RD
Second Line	:
City	:	BEECH ISLAND
State	:	SC
Zip	:	29842-8369
Country	:	US
Telephone Number	:	803-629-7540
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 WILLISTON RD
Second Line	:
City	:	BEECH ISLAND
State	:	SC
Zip	:	29842-8369
Country	:	US
Telephone Number	:	803-629-7540
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. HERBERT ADDISON
Credential	:	J.D., CPED
Telephone Number	:	803-629-7540

Provider Enumeration Date	:	02/20/2012
Last Update Date	:	03/22/2012

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Directions to “CITY OF PEACE, INC ” Practice Location

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