Healthcare Provider Details

I. General information

NPI: 1912813718
Provider Name (Legal Business Name): GRACE HAVEN CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 PINE ST
LANDIS NC
28088-2123
US

IV. Provider business mailing address

507 PINE ST
LANDIS NC
28088-2123
US

V. Phone/Fax

Practice location:
  • Phone: 704-237-0726
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: THURSHELL GRAY
Title or Position: COO
Credential: RN
Phone: 704-237-0726