Healthcare Provider Details

I. General information

NPI: 1043082555
Provider Name (Legal Business Name): HAVEN DETOX OF WEST MEMPHIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2023
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 S AVALON ST
WEST MEMPHIS AR
72301-4183
US

IV. Provider business mailing address

2925 10TH AVE N
PALM SPRINGS FL
33461-3000
US

V. Phone/Fax

Practice location:
  • Phone: 561-635-2400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: KIRILL VESSELOV
Title or Position: PRESIDENT
Credential:
Phone: 561-635-2400