=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811292642
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INLIGHTENED SAFE HAVEN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2011
-----------------------------------------------------
Last Update Date | 01/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 828 NTH 28TH ST.
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-670-1803
-----------------------------------------------------
Fax | 409-670-1803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 828 NTH 28TH ST.
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-670-1803
-----------------------------------------------------
Fax | 409-670-1803
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM MANAGER
-----------------------------------------------------
Name | MRS. STEPHANIE C BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 409-782-1517
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171WH0202X
-----------------------------------------------------
Taxonomy Name | Home Modifications Contractor
-----------------------------------------------------
License Number | 05785017
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------