Provider Demographics
NPI:1841488400
Name:UNIQUE HAVEN RESIDENTIAL SERVICES LLC
Entity type:Organization
Organization Name:UNIQUE HAVEN RESIDENTIAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:DEVON
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-247-3276
Mailing Address - Street 1:106 W CHURCH ST STE A
Mailing Address - Street 2:
Mailing Address - City:CREEDMOOR
Mailing Address - State:NC
Mailing Address - Zip Code:27522-9765
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 W CHURCH ST STE A
Practice Address - Street 2:
Practice Address - City:CREEDMOOR
Practice Address - State:NC
Practice Address - Zip Code:27522-9765
Practice Address - Country:US
Practice Address - Phone:919-247-3276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC039043320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness