Provider Demographics
NPI:1306111984
Name:PEACE WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:PEACE WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:JARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP,BC
Authorized Official - Phone:601-842-7107
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:VAIDEN
Mailing Address - State:MS
Mailing Address - Zip Code:39176-0093
Mailing Address - Country:US
Mailing Address - Phone:601-842-7107
Mailing Address - Fax:800-517-7659
Practice Address - Street 1:638 NORTHWEST AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:MS
Practice Address - Zip Code:39063-3337
Practice Address - Country:US
Practice Address - Phone:601-842-7107
Practice Address - Fax:800-517-7659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR869034261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03607748Medicaid