Healthcare Provider Details

I. General information

NPI: 1750652301
Provider Name (Legal Business Name): EAGLES NEST OF GASTONIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 09/19/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 N PARKWAY STE B4
JACKSON TN
38305-2895
US

IV. Provider business mailing address

PO BOX 163
GASTONIA NC
28053-0163
US

V. Phone/Fax

Practice location:
  • Phone: 980-522-7724
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. GWENDOLYN GAVIN
Title or Position: OWNER
Credential:
Phone: 980-522-7724