=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558224063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAVEN DETOX TULSA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2025
-----------------------------------------------------
Last Update Date | 12/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2130 S 85TH EAST AVE
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74129-3066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-461-3791
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2925 10TH AVE N
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33461-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KIRILL VESSELOV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-461-3791
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------