Healthcare Provider Details

I. General information

NPI: 1235781246
Provider Name (Legal Business Name): BRIGHTHAVEN HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 BRIGHTHAVEN DR
RALEIGH NC
27614-6745
US

IV. Provider business mailing address

5516 PEAKTON DR
RALEIGH NC
27614-9707
US

V. Phone/Fax

Practice location:
  • Phone: 919-846-2308
  • Fax:
Mailing address:
  • Phone: 919-844-6864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: SANTOSH P GAUR
Title or Position: MANAGING MEMBER
Credential:
Phone: 919-844-6864