=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912344458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAVENCREST ALF, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2013
-----------------------------------------------------
Last Update Date | 05/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4280 NW 113TH AVE
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-7778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-345-2362
-----------------------------------------------------
Fax | 954-345-7123
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4280 NW 113TH AVE
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-7778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-345-2362
-----------------------------------------------------
Fax | 954-345-7123
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | YVONNE JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-683-3945
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL9357
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------