Healthcare Provider Details

I. General information

NPI: 1124910849
Provider Name (Legal Business Name): MATERNAL HAVEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 07/17/2025
Certification Date: 06/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 CAMINO DE LA REINA APT 247
SAN DIEGO CA
92108-3095
US

IV. Provider business mailing address

4660 LA JOLLA VILLAGE DR STE 100
SAN DIEGO CA
92122-4604
US

V. Phone/Fax

Practice location:
  • Phone: 619-289-9388
  • Fax:
Mailing address:
  • Phone: 619-289-9388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANDREA PICHATARO
Title or Position: MANAGING MEMBER
Credential: CD
Phone: 619-289-9388