Healthcare Provider Details

I. General information

NPI: 1184489460
Provider Name (Legal Business Name): ETERNAL HAVEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2024
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 ZEBULON AVE SW
CONCORD NC
28027-9209
US

IV. Provider business mailing address

4111 ZEBULON AVE SW
CONCORD NC
28027-9209
US

V. Phone/Fax

Practice location:
  • Phone: 704-796-1156
  • Fax:
Mailing address:
  • Phone: 704-796-1156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. BRANDON BLASSE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 704-796-1156