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General NPI Number Information
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NPI Number | 1073759890
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Entity Type | Organization
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Legal Business Name | HEIDIS HAVEN LLC
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Dates
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Enumeration Date | 12/29/2008
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Last Update Date | 09/14/2016
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Provider Practice Location Address
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Address Line | 39106 GRAYS AIRPORT RD
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City | LADY LAKE
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State | FL
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Zip | 32159-4004
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Country | US
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Telephone | 352-787-3034
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Fax | 352-787-5979
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Provider Business Mailing Address
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Address Line | 51 BARLOW FIELDS DR
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City | HAYESVILLE
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State | NC
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Zip | 28904-9485
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Country | US
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Telephone | 828-389-4915
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Fax |
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Authorized Official
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Title or Position | OWNER/ ADMINISTRATOR
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Name | MR. DONALD WILLIAM JOHNSON
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Credential |
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Telephone | 828-389-4915
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL10397
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License Number State | FL
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