MEDICARE: HAVEN RECOVERY SERVICES

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1104470939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN RECOVERY SERVICES

Provider Business Mailing Address
First Line	:	1902 ARSENAL ST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63118-2503
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1902 ARSENAL ST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63118-2503
Country	:	US
Telephone Number	:	314-930-9384
Fax Number	:

Authorized Official
Title or Position	:	OWNER, CEO
Name	:	CALLAN HOWTON
Credential	:
Telephone Number	:	314-930-9384

Provider Enumeration Date	:	07/30/2019
Last Update Date	:	07/30/2019

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