1912344458 NPI number — HAVENCREST ALF, LLC

Table of content: (NPI 1912344458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912344458 NPI number — HAVENCREST ALF, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAVENCREST ALF, 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:
Provider Other Organization Name Type Code:
6
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:
1912344458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4280 NW 113TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORAL SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33065-7778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-345-2362
Provider Business Mailing Address Fax Number:
954-345-7123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4280 NW 113TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORAL SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33065-7778
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-345-2362
Provider Business Practice Location Address Fax Number:
954-345-7123
Provider Enumeration Date:
05/23/2013

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
YVONNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
954-683-3945

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL9357 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008673600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com