Provider Demographics
NPI:1831827880
Name:FULL LIFE HAVEN
Entity type:Organization
Organization Name:FULL LIFE HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MERE
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:301-379-5088
Mailing Address - Street 1:11731 GLEN MILL RD
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-1916
Mailing Address - Country:US
Mailing Address - Phone:301-379-5088
Mailing Address - Fax:
Practice Address - Street 1:11731 GLEN MILL RD
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-1916
Practice Address - Country:US
Practice Address - Phone:301-379-5088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities