Provider Demographics
NPI:1396095147
Name:KIONONIA HAVEN HOMES, LLC
Entity type:Organization
Organization Name:KIONONIA HAVEN HOMES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FOREMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-266-5496
Mailing Address - Street 1:1444 JEFFREYS ROAD
Mailing Address - Street 2:PMB 273
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804
Mailing Address - Country:US
Mailing Address - Phone:252-266-5496
Mailing Address - Fax:
Practice Address - Street 1:507 TOBACCO RD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27801-6936
Practice Address - Country:US
Practice Address - Phone:252-266-5496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 253J00000X, 320600000X
NC0000000000322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No251S00000XAgenciesCommunity/Behavioral Health
No253J00000XAgenciesFoster Care Agency
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children