Healthcare Provider Details

I. General information

NPI: 1306147335
Provider Name (Legal Business Name): HAVEN CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11670 KADES TRL
HAMPTON GA
30228-4012
US

IV. Provider business mailing address

11670 KADES TRL
HAMPTON GA
30228-4012
US

V. Phone/Fax

Practice location:
  • Phone: 404-841-8099
  • Fax: 404-521-5045
Mailing address:
  • Phone: 404-841-8099
  • Fax: 404-521-5045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number031012968
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number031012968
License Number StateGA

VIII. Authorized Official

Name: MS. CATHY COLLIER
Title or Position: CEO
Credential:
Phone: 404-841-8099