=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720354012
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAVEN CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2012
-----------------------------------------------------
Last Update Date | 03/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11670 KADES TRL
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30228-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-841-8099
-----------------------------------------------------
Fax | 404-284-8395
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11670 KADES TRL
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30228-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-841-8099
-----------------------------------------------------
Fax | 404-284-8395
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. SHERRY GOODDINE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-841-8099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320700000X
-----------------------------------------------------
Taxonomy Name | Physical Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | PCH006808
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | PCH006808
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------