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General NPI Number Information
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NPI Number | 1396095147
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Entity Type | Organization
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Legal Business Name | KIONONIA HAVEN HOMES, LLC
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Dates
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Enumeration Date | 09/19/2012
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Last Update Date | 09/19/2012
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Provider Practice Location Address
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Address Line | 507 TOBACCO RD
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City | ROCKY MOUNT
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State | NC
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Zip | 27801-6936
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Country | US
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Telephone | 252-266-5496
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Fax |
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Provider Business Mailing Address
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Address Line | 1444 JEFFREYS ROAD PMB 273
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City | ROCKY MOUNT
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State | NC
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Zip | 27804
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Country | US
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Telephone | 252-266-5496
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | PAMELA L FOREMAN
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Credential |
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Telephone | 252-266-5496
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 253J00000X
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Taxonomy Name | Foster Care Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 0000000000
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License Number State | NC
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Taxonomy #4
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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