MEDICARE: HAVENPATH SUPPORTIVE LIVING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility
2	385H00000X	Respite Care
3	320800000X	Mental Illness Community Based Residential Treatment Facility
4	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1518839372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVENPATH SUPPORTIVE LIVING LLC

Provider Business Mailing Address
First Line	:	4518 W MARKET ST STE A
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-1543
Country	:	US
Telephone Number	:	704-662-5250
Fax Number	:

Provider Business Practice Location Address
First Line	:	4518 W MARKET ST STE A
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-1543
Country	:	US
Telephone Number	:	704-662-5250
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ROOSEVELT SMITH
Credential	:
Telephone Number	:	704-662-5250

Provider Enumeration Date	:	09/22/2025
Last Update Date	:	01/20/2026

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