Provider Demographics
NPI:1689994709
Name:GAVIN & DOWNEY HEAVENLY LIVING HOME #3
Entity Type:Organization
Organization Name:GAVIN & DOWNEY HEAVENLY LIVING HOME #3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:LOIS
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:252-456-9996
Mailing Address - Street 1:545 ROOKER DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:NORLINA
Mailing Address - State:NC
Mailing Address - Zip Code:27563-9545
Mailing Address - Country:US
Mailing Address - Phone:252-456-2998
Mailing Address - Fax:252-456-2027
Practice Address - Street 1:426 ROOKER DAIRY RD
Practice Address - Street 2:
Practice Address - City:NORLINA
Practice Address - State:NC
Practice Address - Zip Code:27563-9544
Practice Address - Country:US
Practice Address - Phone:252-456-9996
Practice Address - Fax:252-456-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-093-055311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805804Medicaid