1487868170 NPI number — HAVEN BEHAVIORAL SERVICES OF PUEBLO, LLC

Table of content: (NPI 1487868170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487868170 NPI number — HAVEN BEHAVIORAL SERVICES OF PUEBLO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAVEN BEHAVIORAL SERVICES OF PUEBLO, 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:
1487868170
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1008 MINNEQUA AVE
Provider Second Line Business Mailing Address:
SUITE 6100
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81004-3733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-546-6000
Provider Business Mailing Address Fax Number:
719-565-4021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1008 MINNEQUA AVE
Provider Second Line Business Practice Location Address:
SUITE 6100
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81004-3733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-546-6000
Provider Business Practice Location Address Fax Number:
719-565-4021
Provider Enumeration Date:
05/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KELTNER
Authorized Official First Name:
CHRISTY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
AVP / REVENUE CYCLE
Authorized Official Telephone Number:
615-393-8816

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , with the licence number:  APPLIED FOR , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 283Q00000X , with the licence number: 01P254 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 064025 . This is a "MEDICARE A" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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