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General NPI Number Information
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NPI Number | 1013051341
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Entity Type | Organization
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Legal Business Name | MARYHAVEN CENTER OF HOPE INC.
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Dates
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Enumeration Date | 02/19/2007
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Last Update Date | 04/30/2015
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Provider Practice Location Address
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Address Line | 298 LONG ISLAND AVENUE
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City | HOLTSVILLE
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State | NY
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Zip | 11742
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Country | US
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Telephone | 631-758-8479
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Fax | 631-758-9811
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Provider Business Mailing Address
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Address Line | 51 TERRYVILLE ROAD
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776
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Country | US
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Telephone | 631-474-4120
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Fax | 631-474-1312
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Authorized Official
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Title or Position | DIRECTOR OF FINANCE
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Name | LAURA PEPPER
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Credential |
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Telephone | 531-474-4120
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 6824421
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License Number State | NY
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