NPIMap

Organization Active NPI

Peace River Center for Personal Development Inc

Doing business as Peace River Center

  • Psychiatry Physician
  • Bartow, FL
National Provider Identifier
1104572551
Registry record updated Feb 1, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
PEACE RIVER CENTER FOR PERSONAL DEVELOPMENT INC
Doing business as
Peace River Center
Practice address
1255 Golfview Ave
Bartow, FL 33830-6736
Phone
(863) 519-0575
Fax
(863) 582-9251
NPI assigned
Feb 24, 2022
Last updated
Feb 1, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 1, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jo Deck, BA, CPCNPI 1992103964
Title
Credentialing Specialist
Phone
(863) 519-0575

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X
Psychiatry Physician 2084P0800X Primary

Addresses

Primary practice location

1255 Golfview Ave
Bartow, FL 33830-6736

Mailing address

PO Box 1559
Bartow, FL 33831-1559
Phone (863) 519-0575

Other identifiers 1

IdentifierTypeStateIssuer
060310438MedicaidFL

Other names 1

  • Peace River Center Doing business as

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D0292918Peace River Center Crisis Stablilization Unit1255 Golfview Ave, Bartow, FL 33830Certificate of waiverJun 20, 2027

National Provider Directory

National Provider Directory
Tax ID family
Peace River Center for Personal Development Inc14 organizations share this tax ID, including this one

Other organizations with this tax ID 13

Organizations that report the same tax identification number in the National Provider Directory.

View all 13

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1645660800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1675209600000",
    "number": "1104572551",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1559",
            "city": "BARTOW",
            "state": "FL",
            "postal_code": "338311559",
            "telephone_number": "863-519-0575",
            "fax_number": "863-582-9251"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1255 GOLFVIEW AVE",
            "city": "BARTOW",
            "state": "FL",
            "postal_code": "338306736",
            "telephone_number": "863-519-0575",
            "fax_number": "863-582-9251"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEACE RIVER CENTER FOR PERSONAL DEVELOPMENT INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-02-24",
        "last_updated": "2023-02-01",
        "certification_date": "2023-02-01",
        "status": "A",
        "authorized_official_last_name": "DECK",
        "authorized_official_first_name": "JO",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "863-519-0575",
        "authorized_official_credential": "BA, CPC"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "060310438",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Peace River Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Peace River Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bartow, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 1, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.