Healthcare Provider Details

I. General information

NPI: 1437826211
Provider Name (Legal Business Name): HAVEN MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2021
Last Update Date: 08/27/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1332 W HERNDON AVE STE 101
FRESNO CA
93711-7118
US

IV. Provider business mailing address

1332 W HERNDON AVE STE 101
FRESNO CA
93711-7118
US

V. Phone/Fax

Practice location:
  • Phone: 682-433-9287
  • Fax:
Mailing address:
  • Phone: 682-433-9287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTICE OTCHERE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 682-433-9287