Provider Demographics
NPI:1760519201
Name:GAVIN & DOWNEY HEAVENLY LIVING HOME II
Entity Type:Organization
Organization Name:GAVIN & DOWNEY HEAVENLY LIVING HOME II
Other - Org Name:GAVIN & DOWNEY HEAVENLY LIVING HOME I
Other - Org Type:Other Name
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:
Authorized Official - Phone:252-456-9996
Mailing Address - Street 1:119 DOWNEY RD
Mailing Address - Street 2:
Mailing Address - City:NORLINA
Mailing Address - State:NC
Mailing Address - Zip Code:27563-9555
Mailing Address - Country:US
Mailing Address - Phone:252-456-9996
Mailing Address - Fax:252-456-2027
Practice Address - Street 1:107 HARRISON RD
Practice Address - Street 2:
Practice Address - City:NORLINA
Practice Address - State:NC
Practice Address - Zip Code:27563-9558
Practice Address - Country:US
Practice Address - Phone:252-456-2998
Practice Address - Fax:252-456-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-093-041322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603807Medicaid
NC6603807Medicaid