Healthcare Provider Details

I. General information

NPI: 1225455066
Provider Name (Legal Business Name): REBEKAHS HAVEN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2014
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

791 HAVERHILL RD N
HAVERHILL FL
33415-1342
US

IV. Provider business mailing address

791 HAVERHILL RD N
HAVERHILL FL
33415-1342
US

V. Phone/Fax

Practice location:
  • Phone: 561-373-8656
  • Fax:
Mailing address:
  • Phone: 561-373-8656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number10D2074273
License Number StateFL

VIII. Authorized Official

Name: MR. PABLO LOPEZ DE LEON
Title or Position: PRESIDENT
Credential:
Phone: 561-355-6929