Healthcare Provider Details

I. General information

NPI: 1215404132
Provider Name (Legal Business Name): HAVEN ORTHOPEDICS & SPINE INSTITUTE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10390 COMMERCE CENTER DR STE C100
RANCHO CUCAMONGA CA
91730-5858
US

IV. Provider business mailing address

10390 COMMERCE CENTER DR STE C100
RANCHO CUCAMONGA CA
91730-5858
US

V. Phone/Fax

Practice location:
  • Phone: 909-372-0000
  • Fax:
Mailing address:
  • Phone: 909-372-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: FADY ELIAS
Title or Position: MD
Credential: MD
Phone: 909-372-0000