1093079303 NPI number — HAVEN BEHAVIORAL SERVICES OF ALBUQUERQUE, LLC

Table of content: (NPI 1093079303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093079303 NPI number — HAVEN BEHAVIORAL SERVICES OF ALBUQUERQUE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAVEN BEHAVIORAL SERVICES OF ALBUQUERQUE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HAVEN BEHAVIORAL HOSPITAL OF ALBUQUERQUE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093079303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3102 W END AVE
Provider Second Line Business Mailing Address:
SUITE 1000
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37203-1301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-393-8826
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5400 GIBSON BLVD SE
Provider Second Line Business Practice Location Address:
4TH FLOOR
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87108-4729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-393-8826
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PICKLE
Authorized Official First Name:
JANIE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
VP/TREASURER
Authorized Official Telephone Number:
615-250-9064

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , with the licence number:  2T3426 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 08652856 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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