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General NPI Number Information
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NPI Number | 1760875728
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Entity Type | Organization
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Legal Business Name | LAVERNE'S HAVEN RESIDENTIAL SERVICES
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Dates
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Enumeration Date | 03/13/2015
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Last Update Date | 03/13/2015
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Provider Practice Location Address
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Address Line | 195 BROOKSIDE DR
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City | EDEN
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State | NC
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Zip | 27288-8123
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Country | US
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Telephone | 336-627-3262
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Fax |
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Provider Business Mailing Address
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Address Line | 7022 LAKEVIEW TER
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City | DANVILLE
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State | VA
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Zip | 24540-8248
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Country | US
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Telephone | 434-489-2469
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Fax |
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | MR. JEFFERY LYNN WOMACK
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Credential |
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Telephone | 434-489-2469
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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