Provider Demographics
NPI:1760875728
Name:LAVERNE'S HAVEN RESIDENTIAL SERVICES
Entity Type:Organization
Organization Name:LAVERNE'S HAVEN RESIDENTIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WOMACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-489-2469
Mailing Address - Street 1:7022 LAKEVIEW TER
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-8248
Mailing Address - Country:US
Mailing Address - Phone:434-489-2469
Mailing Address - Fax:
Practice Address - Street 1:195 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-8123
Practice Address - Country:US
Practice Address - Phone:336-627-3262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities