1346565595 NPI number — HAVENWOOD CAREGIVER SERVICES

Table of content: (NPI 1346565595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346565595 NPI number — HAVENWOOD CAREGIVER SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAVENWOOD CAREGIVER SERVICES
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:
OKEEFFE ENTERPRISES, LLC
Provider Other Organization Name Type Code:
4
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:
1346565595
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2417 N COLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83704-5907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-327-1011
Provider Business Mailing Address Fax Number:
208-327-1411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 E WELLESLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99207-1578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-535-1546
Provider Business Practice Location Address Fax Number:
509-535-4635
Provider Enumeration Date:
03/31/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OKEEFFE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
208-327-1011

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  IHS.FS.00000308 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 253Z00000X , with the licence number: M8072875 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 359880 . This is a "WASHINGTON STATE ALTCEW" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 359880 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: M8072875 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".