1326654393 NPI number — PEACE HEALTH AND WELLNESS CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326654393 NPI number — PEACE HEALTH AND WELLNESS CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACE HEALTH AND WELLNESS CLINIC
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:
1326654393
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
830 MAYFIELD RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND PRAIRIE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75052-3728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-999-0009
Provider Business Mailing Address Fax Number:
469-242-9693

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
830 MAYFIELD RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND PRAIRIE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75052-3728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-999-0009
Provider Business Practice Location Address Fax Number:
469-242-9693
Provider Enumeration Date:
09/16/2020

Additional Information

Authorized Official

Authorized Official Last Name:
AWE
Authorized Official First Name:
OLUBUNMI
Authorized Official Middle Name:
ROSELINE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
214-400-2000

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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