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General NPI Number Information
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NPI Number | 1427013655
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Entity Type | Organization
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Legal Business Name | HENDERSON HAVEN INC
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Dates
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Enumeration Date | 04/19/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 2554 MOODY AVE
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City | ORANGE PARK
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State | FL
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Zip | 32073-5937
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Country | US
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Telephone | 904-264-2522
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Fax | 904-215-7338
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Provider Business Mailing Address
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Address Line | 2554 MOODY AVE
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City | ORANGE PARK
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State | FL
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Zip | 32073-5937
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Country | US
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Telephone | 904-264-2522
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Fax | 904-215-7338
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Authorized Official
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Title or Position | PRES CEO
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Name | LEE HENDERSON
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Credential |
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Telephone | 904-264-2522
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251V00000X
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Taxonomy Name | Voluntary or Charitable Agency
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License Number | CH17033
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | F001
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | F001
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License Number State | FL
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