Provider Demographics
NPI:1487170759
Name:MY PEACE KEEPER II INC.
Entity type:Organization
Organization Name:MY PEACE KEEPER II INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:POUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-505-0902
Mailing Address - Street 1:3119 SPRING GLEN RD STE 104
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5921
Mailing Address - Country:US
Mailing Address - Phone:980-505-0902
Mailing Address - Fax:704-919-5055
Practice Address - Street 1:3119 SPRING GLEN RD STE 104
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5921
Practice Address - Country:US
Practice Address - Phone:980-505-0902
Practice Address - Fax:704-919-5055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health