MEDICARE: HENDERSON HAVEN INC

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	251V00000X	Voluntary or Charitable Agency	CH17033	FL
2	305S00000X	Point of Service	F001	FL
3	251C00000X	Developmentally Disabled Services Day Training Agency	F001	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427013655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HENDERSON HAVEN INC

Provider Business Mailing Address
First Line	:	2554 MOODY AVE
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-5937
Country	:	US
Telephone Number	:	904-264-2522
Fax Number	:	904-215-7338

Provider Business Practice Location Address
First Line	:	2554 MOODY AVE
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-5937
Country	:	US
Telephone Number	:	904-264-2522
Fax Number	:	904-215-7338

Authorized Official
Title or Position	:	PRES CEO
Name	:	LEE HENDERSON
Credential	:
Telephone Number	:	904-264-2522

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	07/21/2022

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