=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013152578
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEAVENLYGATES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2008
-----------------------------------------------------
Last Update Date | 12/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1407 DUNBAR ST
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27401-3801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-617-3036
-----------------------------------------------------
Fax | 336-617-3036
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1407 DUNBAR ST
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27401-3801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-617-3036
-----------------------------------------------------
Fax | 336-617-3036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | TARSHA VIOLET HOWARD
-----------------------------------------------------
Credential | L.P.N.
-----------------------------------------------------
Telephone | 336-254-3137
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | MHL-041-882
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------