MEDICARE: HAVEN OF DOUGLAS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility
2	314000000X	Skilled Nursing Facility	NCI-2708	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073850319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN OF DOUGLAS, LLC

Provider Business Mailing Address
First Line	:	1400 N SAN ANTONIO AVE
Second Line	:
City	:	DOUGLAS
State	:	AZ
Zip	:	85607-2434
Country	:	US
Telephone Number	:	520-364-7937
Fax Number	:	520-805-9146

Provider Business Practice Location Address
First Line	:	1400 N SAN ANTONIO AVE
Second Line	:
City	:	DOUGLAS
State	:	AZ
Zip	:	85607-2434
Country	:	US
Telephone Number	:	520-364-7937
Fax Number	:	520-805-9146

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRETT P ROBERTSON
Credential	:
Telephone Number	:	480-935-4300

Provider Enumeration Date	:	01/07/2013
Last Update Date	:	05/22/2025

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Directions to “HAVEN OF DOUGLAS, LLC ” Practice Location

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