MEDICARE: UNIQUE HAVEN RESIDENTIAL SERVICES LLC

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	320800000X	Mental Illness Community Based Residential Treatment Facility	039043	NC

General Provider Information

NPI Number	:	1841488400
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIQUE HAVEN RESIDENTIAL SERVICES LLC

Provider Business Mailing Address
First Line	:	106 W CHURCH ST STE A
Second Line	:
City	:	CREEDMOOR
State	:	NC
Zip	:	27522-9765
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 W CHURCH ST STE A
Second Line	:
City	:	CREEDMOOR
State	:	NC
Zip	:	27522-9765
Country	:	US
Telephone Number	:	919-247-3276
Fax Number	:

Authorized Official
Title or Position	:	STAFF COORDINATOR
Name	:	DERRICK DEVON DAVIS
Credential	:
Telephone Number	:	919-247-3276

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	10/09/2007

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