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General NPI Number Information
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NPI Number | 1891282927
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Entity Type | Individual
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Provider Name | JUSTIN HAVENS
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Gender | Male
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Dates
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Enumeration Date | 04/14/2018
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Last Update Date | 09/07/2023
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Provider Practice Location Address
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Address Line | 1717 HARPER RD FL 2
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City | BECKLEY
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State | WV
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Zip | 25801-3373
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Country | US
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Telephone | 681-207-7563
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Fax |
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Provider Business Mailing Address
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Address Line | 10099 RIDGEGATE PKWY STE 200
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City | LONE TREE
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State | CO
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Zip | 80124-5532
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Country | US
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Telephone | 434-987-4148
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 4157
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License Number State | WV
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