Provider Demographics
NPI:1447447362
Name:PEACE IN YOUNG LIFE CENTER, INC.
Entity type:Organization
Organization Name:PEACE IN YOUNG LIFE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCHELLE
Authorized Official - Middle Name:MITZI
Authorized Official - Last Name:GAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-263-2533
Mailing Address - Street 1:717 E LINE ST
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-2271
Mailing Address - Country:US
Mailing Address - Phone:706-629-2212
Mailing Address - Fax:706-629-6613
Practice Address - Street 1:717 E LINE ST
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-2271
Practice Address - Country:US
Practice Address - Phone:706-629-2212
Practice Address - Fax:706-629-2213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA064010111320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA007422496AMedicaid
MI=========OtherEIN