MEDICARE: HAVEN HEALTHKARE SERVICES

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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1235900416
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN HEALTHKARE SERVICES

Provider Business Mailing Address
First Line	:	5320 N MAIN ST # 2A
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45415-3657
Country	:	US
Telephone Number	:	937-567-0638
Fax Number	:	937-567-0698

Provider Business Practice Location Address
First Line	:	5320 N MAIN ST # 2A
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45415-3657
Country	:	US
Telephone Number	:	937-567-0638
Fax Number	:	937-567-0698

Authorized Official
Title or Position	:	CEO
Name	:	MR. CLIVE FOMENKY
Credential	:
Telephone Number	:	937-248-6394

Provider Enumeration Date	:	01/16/2024
Last Update Date	:	01/16/2024

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