1700418977 NPI number — PEACEFUL CARE LIMITED LIABILITY COMPANY

Table of content: MRS. ANDREA N. JOHNSON LCPC (NPI 1568493336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700418977 NPI number — PEACEFUL CARE LIMITED LIABILITY COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACEFUL CARE LIMITED LIABILITY COMPANY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700418977
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10560 AUBURNDALE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAGRIN FALLS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44023-2344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-201-3381
Provider Business Mailing Address Fax Number:
612-234-4361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2415 ANNAPOLIS LN N STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55441-3632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-701-6094
Provider Business Practice Location Address Fax Number:
763-205-6574
Provider Enumeration Date:
02/06/2020

Additional Information

Authorized Official

Authorized Official Last Name:
CREWS
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATIONS OFFICER
Authorized Official Telephone Number:
612-701-6094

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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