MEDICARE: HAVEN DETOX TULSA 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	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1558224063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN DETOX TULSA LLC

Provider Business Mailing Address
First Line	:	2925 10TH AVE N
Second Line	:
City	:	PALM SPRINGS
State	:	FL
Zip	:	33461-3000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2130 S 85TH EAST AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74129-3066
Country	:	US
Telephone Number	:	561-461-3791
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KIRILL VESSELOV
Credential	:
Telephone Number	:	561-461-3791

Provider Enumeration Date	:	12/03/2025
Last Update Date	:	12/03/2025

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