Healthcare Provider Details

I. General information

NPI: 1619011830
Provider Name (Legal Business Name): HAVENS FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 03/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 LATIGO LN SUITE C
CANON CITY CO
81212-8112
US

IV. Provider business mailing address

109 LATIGO LN SUITE C
CANON CITY CO
81212-8112
US

V. Phone/Fax

Practice location:
  • Phone: 719-276-3211
  • Fax:
Mailing address:
  • Phone: 719-276-3211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28791
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2124
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP4805
License Number StateCO

VIII. Authorized Official

Name: JASON MORGAN
Title or Position: OFFICE MANAGER
Credential: PA
Phone: 719-276-3211