Healthcare Provider Details

I. General information

NPI: 1003623018
Provider Name (Legal Business Name): DAVINA'S HAVEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 02/22/2025
Certification Date: 02/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 JAGER DR NE STE C4
RIO RANCHO NM
87144-5715
US

IV. Provider business mailing address

4405 JAGER DR NE STE C4
RIO RANCHO NM
87144-5715
US

V. Phone/Fax

Practice location:
  • Phone: 505-906-0002
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DANIELRAY MOISES BLEA SMITH
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 505-906-0002