Healthcare Provider Details

I. General information

NPI: 1558062059
Provider Name (Legal Business Name): MISSION HAVEN REDIEMED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6108 SHOREWOOD DR
ARLINGTON TX
76016-2649
US

IV. Provider business mailing address

PO BOX 170428
ARLINGTON TX
76003-0428
US

V. Phone/Fax

Practice location:
  • Phone: 817-435-2812
  • Fax:
Mailing address:
  • Phone: 817-435-2812
  • Fax: 817-719-9236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ABI MIKKEL PROVENCE
Title or Position: OWNER AND PROVIDER
Credential: APRN, FNP-BC, FNP-C
Phone: 817-992-9791