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General NPI Number Information
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NPI Number | 1619011830
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Entity Type | Organization
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Legal Business Name | HAVENS FAMILY CLINIC
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Dates
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Enumeration Date | 02/19/2007
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Last Update Date | 03/23/2012
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Provider Practice Location Address
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Address Line | 109 LATIGO LN SUITE C
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City | CANON CITY
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State | CO
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Zip | 81212-8112
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Country | US
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Telephone | 719-276-3211
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Fax |
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Provider Business Mailing Address
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Address Line | 109 LATIGO LN SUITE C
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City | CANON CITY
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State | CO
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Zip | 81212-8112
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Country | US
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Telephone | 719-276-3211
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JASON MORGAN
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Credential | PA
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Telephone | 719-276-3211
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 2124
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | NP4805
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License Number State | CO
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 28791
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License Number State | CO
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