Healthcare Provider Details

I. General information

NPI: 1407389794
Provider Name (Legal Business Name): GRACE HAVEN MINISTRIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 JOHNSON RD
SPRINGDALE AR
72762-6022
US

IV. Provider business mailing address

PO BOX 956
ROGERS AR
72757-0956
US

V. Phone/Fax

Practice location:
  • Phone: 501-420-4515
  • Fax:
Mailing address:
  • Phone: 501-420-4515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ANNIE MARTIN
Title or Position: DIRECTOR OF FAMILY SERVICES
Credential:
Phone: 479-633-2288