Healthcare Provider Details

I. General information

NPI: 1891266557
Provider Name (Legal Business Name): NICKELI'S SAFE HAVEN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9057 S PARNELL AVE
CHICAGO IL
60620-2240
US

IV. Provider business mailing address

9057 S PARNELL AVE
CHICAGO IL
60620-2240
US

V. Phone/Fax

Practice location:
  • Phone: 773-960-3024
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: BRANDYN GARNER
Title or Position: PRESIDENT
Credential: LPN
Phone: 773-960-3024