Healthcare Provider Details

I. General information

NPI: 1104810852
Provider Name (Legal Business Name): HAVEN NURSING HOME CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 TERRACE LN
MEXIA TX
76667-2072
US

IV. Provider business mailing address

601 TERRACE LN
MEXIA TX
76667-2072
US

V. Phone/Fax

Practice location:
  • Phone: 254-562-5400
  • Fax: 254-562-9145
Mailing address:
  • Phone: 254-562-5400
  • Fax: 254-562-9145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number109191
License Number StateTX

VIII. Authorized Official

Name: MRS. DONNA WILLIFORD
Title or Position: ADMINISTRATOR
Credential:
Phone: 254-562-5400