Healthcare Provider Details

I. General information

NPI: 1538733076
Provider Name (Legal Business Name): GRACEHAVEN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 ARLINGTON CENTRE BLVD STE 2277B
COLUMBUS OH
43220-3084
US

IV. Provider business mailing address

5000 ARLINGTON CENTRE BLVD STE 2277B
COLUMBUS OH
43220-3084
US

V. Phone/Fax

Practice location:
  • Phone: 614-302-9515
  • Fax:
Mailing address:
  • Phone: 614-302-9515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: PAUL FULLER
Title or Position: INTERIM DIRECTOR
Credential:
Phone: 614-302-9515