MEDICARE: GAVIN & DOWNEY HEAVENLY LIVING HOME II

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	MHL-093-041	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760519201
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GAVIN & DOWNEY HEAVENLY LIVING HOME II

Provider Business Mailing Address
First Line	:	119 DOWNEY RD
Second Line	:
City	:	NORLINA
State	:	NC
Zip	:	27563-9555
Country	:	US
Telephone Number	:	252-456-9996
Fax Number	:	252-456-2027

Provider Business Practice Location Address
First Line	:	107 HARRISON RD
Second Line	:
City	:	NORLINA
State	:	NC
Zip	:	27563-9558
Country	:	US
Telephone Number	:	252-456-2998
Fax Number	:	252-456-2027

Authorized Official
Title or Position	:	OWNER
Name	:	MS. ANN LOIS GAVIN
Credential	:
Telephone Number	:	252-456-9996

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	08/22/2020

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