Provider Demographics
NPI:1265680805
Name:NEW HEAVEN DOMINION, INC
Entity Type:Organization
Organization Name:NEW HEAVEN DOMINION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-790-0721
Mailing Address - Street 1:12355 FINNS COVE TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-4198
Mailing Address - Country:US
Mailing Address - Phone:904-790-0721
Mailing Address - Fax:904-619-6025
Practice Address - Street 1:9146 RIDGE BRIER LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-9325
Practice Address - Country:US
Practice Address - Phone:904-647-6651
Practice Address - Fax:904-647-6653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL02084206251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health