Provider Demographics
NPI:1013152578
Name:HEAVENLYGATES, INC.
Entity Type:Organization
Organization Name:HEAVENLYGATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TARSHA
Authorized Official - Middle Name:VIOLET
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:336-254-3137
Mailing Address - Street 1:1407 DUNBAR ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-3801
Mailing Address - Country:US
Mailing Address - Phone:336-617-3036
Mailing Address - Fax:336-617-3036
Practice Address - Street 1:1407 DUNBAR ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-3801
Practice Address - Country:US
Practice Address - Phone:336-617-3036
Practice Address - Fax:336-617-3036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-882320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities