Healthcare Provider Details

I. General information

NPI: 1396214086
Provider Name (Legal Business Name): DESERT HAVEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E IDAHO AVE STE 25
LAS CRUCES NM
88005-3242
US

IV. Provider business mailing address

PO BOX 1676
FAIRACRES NM
88033-1676
US

V. Phone/Fax

Practice location:
  • Phone: 575-571-1016
  • Fax:
Mailing address:
  • Phone: 575-571-1016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name: CHARLES GATES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 575-571-1016