Provider Demographics
NPI:1598946873
Name:THE HAVEN
Entity Type:Organization
Organization Name:THE HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GULLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-269-9524
Mailing Address - Street 1:PO BOX 1377
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:NC
Mailing Address - Zip Code:27597-1377
Mailing Address - Country:US
Mailing Address - Phone:919-269-9524
Mailing Address - Fax:
Practice Address - Street 1:310 W HORTON ST
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-2520
Practice Address - Country:US
Practice Address - Phone:919-269-9524
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-092-054311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803184Medicaid