Provider Demographics
NPI:1043354681
Name:MARYHAVEN CENTER OF HOPE INC.
Entity Type:Organization
Organization Name:MARYHAVEN CENTER OF HOPE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-474-4120
Mailing Address - Street 1:51 TERRYVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776
Mailing Address - Country:US
Mailing Address - Phone:631-474-4120
Mailing Address - Fax:631-474-1312
Practice Address - Street 1:450 MYRTLE AVENUE
Practice Address - Street 2:HOUSE 1
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-331-6186
Practice Address - Fax:631-331-3974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00883298Medicaid