Healthcare Provider Details

I. General information

NPI: 1427191766
Provider Name (Legal Business Name): ABUNDANCE SAFE HAVEN INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1156 DELANO ST
DURHAM NC
27703-2244
US

IV. Provider business mailing address

1821 HILLANDALE RD 1B
DURHAM NC
27705-2659
US

V. Phone/Fax

Practice location:
  • Phone: 919-680-2030
  • Fax: 919-682-6637
Mailing address:
  • Phone: 919-680-2030
  • Fax: 919-682-6637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberMHL-032-387
License Number StateNC

VIII. Authorized Official

Name: MR. TERRON H. SIMPSON SR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 919-680-2030