MEDICARE: PEACEFUL SURROUNDINGS 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	1028	VA

General Provider Information

NPI Number	:	1578796611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACEFUL SURROUNDINGS LLC

Provider Business Mailing Address
First Line	:	332 DORSET AVE
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-6619
Country	:	US
Telephone Number	:	757-493-9302
Fax Number	:

Provider Business Practice Location Address
First Line	:	332 DORSET AVE
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-6619
Country	:	US
Telephone Number	:	757-493-9302
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. MARSHA SIMPKINS
Credential	:
Telephone Number	:	757-467-5340

Provider Enumeration Date	:	08/24/2009
Last Update Date	:	08/24/2009

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