Healthcare Provider Details

I. General information

NPI: 1710302971
Provider Name (Legal Business Name): DREAM HAVEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 E MORRISON ST
EDGERTON OH
43517-9302
US

IV. Provider business mailing address

233 E MORRISON ST
EDGERTON OH
43517-9302
US

V. Phone/Fax

Practice location:
  • Phone: 419-298-3377
  • Fax:
Mailing address:
  • Phone: 419-298-3377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number04-2260
License Number StateOH

VIII. Authorized Official

Name: PEGGE SINES
Title or Position: OWNER
Credential:
Phone: 419-298-3377