1194252304 NPI number — PEACEFUL PINES HEALING PRACTICES, LLC

Table of content: (NPI 1194252304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194252304 NPI number — PEACEFUL PINES HEALING PRACTICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACEFUL PINES HEALING PRACTICES, LLC
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:
1194252304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W3470 BADGER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINE RIVER
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54965-8118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-229-3929
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W3470 BADGER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE RIVER
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54965-8118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-229-3929
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SYKE
Authorized Official First Name:
ANNA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER OF PRACTICE
Authorized Official Telephone Number:
920-229-3929

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  5328-125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1861810194 . This is a "INDIVIDUAL NPI FOR OWNER OF PRACTICE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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