Healthcare Provider Details

I. General information

NPI: 1245780964
Provider Name (Legal Business Name): ANGELS' SAFE HAVEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2571 N. 149TH AVE
GOODYEAR AZ
85395
US

IV. Provider business mailing address

P.O. BOX 7206
SURPRISE AZ
85374
US

V. Phone/Fax

Practice location:
  • Phone: 623-440-4086
  • Fax: 623-440-5939
Mailing address:
  • Phone: 623-210-6382
  • Fax: 623-440-5939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberBH5019
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD EDWARD HORNE
Title or Position: CEO
Credential:
Phone: 623-210-6382