Provider Demographics
NPI:1730843814
Name:A PEACEFUL HOME OF LEWISTON
Entity type:Organization
Organization Name:A PEACEFUL HOME OF LEWISTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:BERRY
Authorized Official - Last Name:ST JUSTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-536-6967
Mailing Address - Street 1:2908 102ND AVE E
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-9203
Mailing Address - Country:US
Mailing Address - Phone:941-536-6967
Mailing Address - Fax:
Practice Address - Street 1:22456 LEWISTON AVE
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-7172
Practice Address - Country:US
Practice Address - Phone:941-536-6967
Practice Address - Fax:941-460-4387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care