MEDICARE: HAVEN YOUTH SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility	SS18205	VA

General Provider Information

NPI Number	:	1073673869
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN YOUTH SERVICES LLC

Provider Business Mailing Address
First Line	:	3122 W MARSHALL ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23230-4726
Country	:	US
Telephone Number	:	804-340-5220
Fax Number	:	804-340-5222

Provider Business Practice Location Address
First Line	:	3122 W MARSHALL ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23230-4726
Country	:	US
Telephone Number	:	804-340-5220
Fax Number	:	804-340-5222

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DARREL CALLIS
Credential	:
Telephone Number	:	804-833-2879

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	08/22/2020

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