Provider Demographics
NPI:1104219567
Name:GAYLAIN'S HOUSE OF HOPE
Entity Type:Organization
Organization Name:GAYLAIN'S HOUSE OF HOPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:LCAS
Authorized Official - Phone:704-491-0829
Mailing Address - Street 1:322 MCBEE ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28092-2819
Mailing Address - Country:US
Mailing Address - Phone:704-240-9453
Mailing Address - Fax:704-240-9431
Practice Address - Street 1:322 MCBEE STRRET
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-2818
Practice Address - Country:US
Practice Address - Phone:047-240-9453
Practice Address - Fax:704-360-2544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-10
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320800000X
NCMHL-055-121324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL-055-121OtherDHSR