Healthcare Provider Details

I. General information

NPI: 1780451286
Provider Name (Legal Business Name): COMMUNITY HAVEN CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2023
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 E MERCED AVE
WEST COVINA CA
91790-5223
US

IV. Provider business mailing address

818 E MERCED AVE
WEST COVINA CA
91790-5223
US

V. Phone/Fax

Practice location:
  • Phone: 626-918-2991
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: EDWIN EVANGELISTA
Title or Position: ADMINISTRATOR
Credential:
Phone: 626-290-4772