Healthcare Provider Details

I. General information

NPI: 1629128970
Provider Name (Legal Business Name): BETH HAVEN GROUP HOMES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2518 PLEASANT ST
HANNIBAL MO
63401-2659
US

IV. Provider business mailing address

2500 PLEASANT ST
HANNIBAL MO
63401-2600
US

V. Phone/Fax

Practice location:
  • Phone: 573-221-2258
  • Fax:
Mailing address:
  • Phone: 573-221-2258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL EWERT
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 573-221-2258