Provider Demographics
NPI:1184489460
Name:ETERNAL HAVEN LLC
Entity type:Organization
Organization Name:ETERNAL HAVEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:BLASSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-796-1156
Mailing Address - Street 1:4111 ZEBULON AVE SW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-9209
Mailing Address - Country:US
Mailing Address - Phone:704-796-1156
Mailing Address - Fax:
Practice Address - Street 1:4111 ZEBULON AVE SW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-9209
Practice Address - Country:US
Practice Address - Phone:704-796-1156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-16
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness