Healthcare Provider Details

I. General information

NPI: 1043008329
Provider Name (Legal Business Name): SAFE HAVEN HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 04/28/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1677 MAIN STREET
FAYETTE MS
39069
US

IV. Provider business mailing address

1080 GREAT POINT RD
MCCOMB MS
39648-4753
US

V. Phone/Fax

Practice location:
  • Phone: 601-341-3916
  • Fax:
Mailing address:
  • Phone: 601-341-3916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MISS LATOYA RENEE CAMERON
Title or Position: CEO
Credential: NP
Phone: 601-341-3916