Healthcare Provider Details

I. General information

NPI: 1245374560
Provider Name (Legal Business Name): MARYHAVEN CENTER OF HOPE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 EASTPORT MANOR ROAD
MANORVILLE NY
11949
US

IV. Provider business mailing address

51 TERRYVILLE ROAD
PORT JEFFERSON STATION NY
11776
US

V. Phone/Fax

Practice location:
  • Phone: 631-325-8532
  • Fax: 631-325-2261
Mailing address:
  • Phone: 631-474-4120
  • Fax: 631-474-1312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number6639496
License Number StateNY

VIII. Authorized Official

Name: LAURA PEPPER
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 631-474-4120