Provider Demographics
NPI:1396200416
Name:PEACEFUL HOME ASSISTED LIVING, INC
Entity type:Organization
Organization Name:PEACEFUL HOME ASSISTED LIVING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:YASSIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-203-5035
Mailing Address - Street 1:1731 SELBY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6154
Mailing Address - Country:US
Mailing Address - Phone:612-203-5035
Mailing Address - Fax:651-644-7041
Practice Address - Street 1:1186 SAINT PAUL AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-2557
Practice Address - Country:US
Practice Address - Phone:612-203-5035
Practice Address - Fax:651-644-7041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-02
Last Update Date:2019-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances