=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194169037
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAVEN HILLS THERAPEUTIC RIDING CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2013
-----------------------------------------------------
Last Update Date | 04/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7580 RIVERTOWN RD
-----------------------------------------------------
City | FAIRBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30213-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-296-9693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7580 RIVERTOWN RD
-----------------------------------------------------
City | FAIRBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30213-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-296-9693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CERTIFIED REHABILITATION COUNSELOR
-----------------------------------------------------
Name | HEILI S RANDALL
-----------------------------------------------------
Credential | CRC
-----------------------------------------------------
Telephone | 770-371-7531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 00116431
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------