Healthcare Provider Details

I. General information

NPI: 1427013655
Provider Name (Legal Business Name): HENDERSON HAVEN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2554 MOODY AVE
ORANGE PARK FL
32073-5937
US

IV. Provider business mailing address

2554 MOODY AVE
ORANGE PARK FL
32073-5937
US

V. Phone/Fax

Practice location:
  • Phone: 904-264-2522
  • Fax: 904-215-7338
Mailing address:
  • Phone: 904-264-2522
  • Fax: 904-215-7338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License NumberCH17033
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberF001
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberF001
License Number StateFL

VIII. Authorized Official

Name: LEE HENDERSON
Title or Position: PRES CEO
Credential:
Phone: 904-264-2522