=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598946873
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE HAVEN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2007
-----------------------------------------------------
Last Update Date | 11/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 W HORTON ST
-----------------------------------------------------
City | ZEBULON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27597-2520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-269-9524
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1377
-----------------------------------------------------
City | ZEBULON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27597-1377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-269-9524
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. GWENDOLYN GULLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-269-9524
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | FCL-092-054
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------