1205209004 NPI number — THE HAVEN DETOX FT. PIERCE, LLC

Table of content: (NPI 1205209004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205209004 NPI number — THE HAVEN DETOX FT. PIERCE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE HAVEN DETOX FT. PIERCE, 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:
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:
1205209004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3951 HAVERHILL RD N
Provider Second Line Business Mailing Address:
APT 120-121
Provider Business Mailing Address City Name:
WEST PALM BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33417-8154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-616-9000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4707 OLEANDER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT PIERCE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34982-4209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-616-9000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
VESSELOV
Authorized Official First Name:
KIRILL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-616-9000

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , 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)





Copyright © 2007-2025 www.npivalidator.com