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General NPI Number Information
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NPI Number | 1265845499
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Entity Type | Organization
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Legal Business Name | THE HAVEN HOME
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Dates
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Enumeration Date | 06/05/2014
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Last Update Date | 06/05/2014
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Provider Practice Location Address
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Address Line | 1216 HOLT AVE
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City | DESOTO
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State | TX
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Zip | 75115-3110
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Country | US
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Telephone | 972-803-5605
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Fax | 972-803-5605
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Provider Business Mailing Address
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Address Line | 1216 HOLT AVE
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City | DESOTO
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State | TX
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Zip | 75115-3110
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Country | US
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Telephone | 972-803-5605
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Fax | 972-803-5605
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Authorized Official
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Title or Position | OWNER
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Name | MS. SCHNIKWA LAS HICKS
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Credential | NA
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Telephone | 469-734-7674
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 139524
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License Number State | TX
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