Provider Demographics
NPI:1073336194
Name:PEACEFUL GROUP HOME LLC
Entity type:Organization
Organization Name:PEACEFUL GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GENTILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MWIZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-368-3657
Mailing Address - Street 1:1476 BENTREE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7398
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1476 BENTREE DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-7398
Practice Address - Country:US
Practice Address - Phone:614-368-3657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care