Provider Demographics
NPI:1679802631
Name:MY PEACE KEEPER INC
Entity type:Organization
Organization Name:MY PEACE KEEPER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:POUGH
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:704-531-5656
Mailing Address - Street 1:7504 E INDEPENDENCE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-9407
Mailing Address - Country:US
Mailing Address - Phone:704-531-5656
Mailing Address - Fax:704-531-9711
Practice Address - Street 1:7504 E INDEPENDENCE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-9407
Practice Address - Country:US
Practice Address - Phone:704-531-5656
Practice Address - Fax:704-531-9711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & FamilyGroup - Multi-Specialty