Healthcare Provider Details

I. General information

NPI: 1073850319
Provider Name (Legal Business Name): HAVEN OF DOUGLAS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N SAN ANTONIO AVE
DOUGLAS AZ
85607-2434
US

IV. Provider business mailing address

1400 N SAN ANTONIO AVE
DOUGLAS AZ
85607-2434
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-7937
  • Fax: 520-805-9146
Mailing address:
  • Phone: 520-364-7937
  • Fax: 520-805-9146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNCI-2708
License Number StateAZ

VIII. Authorized Official

Name: BRETT P ROBERTSON
Title or Position: PRESIDENT
Credential:
Phone: 480-935-4300