MEDICARE: HAVEN RECOVERY AZ 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	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1396115234
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN RECOVERY AZ LLC

Provider Business Mailing Address
First Line	:	9524 W CAMELBACK RD
Second Line	:	STE C-130, #293
City	:	GLENDALE
State	:	AZ
Zip	:	85305-3104
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9524 W CAMELBACK RD
Second Line	:	STE C-130, #293
City	:	GLENDALE
State	:	AZ
Zip	:	85305-3104
Country	:	US
Telephone Number	:	405-834-2993
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	ERICH BRUESCHKE
Credential	:
Telephone Number	:	405-834-2993

Provider Enumeration Date	:	10/05/2015
Last Update Date	:	10/05/2015

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