Healthcare Provider Details

I. General information

NPI: 1588171706
Provider Name (Legal Business Name): TONY HAVENS LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 NE GREENWOOD AVE # A
BEND OR
97701-4607
US

IV. Provider business mailing address

461 NE GREENWOOD AVE # A
BEND OR
97701-4607
US

V. Phone/Fax

Practice location:
  • Phone: 541-241-3135
  • Fax:
Mailing address:
  • Phone: 541-241-3135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberACC222417
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number12547
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: