MEDICARE: HAVEN CORPORATION

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	251S00000X	Community/Behavioral Health Agency	5586	CO

General Provider Information

NPI Number	:	1528382512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN CORPORATION

Provider Business Mailing Address
First Line	:	1155 KELLY JOHNSON BLVD
Second Line	:	SUITE 111
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-3932
Country	:	US
Telephone Number	:	719-590-4124
Fax Number	:	719-448-0870

Provider Business Practice Location Address
First Line	:	1155 KELLY JOHNSON BLVD
Second Line	:	SUITE 111
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-3932
Country	:	US
Telephone Number	:	719-590-4124
Fax Number	:	719-448-0870

Authorized Official
Title or Position	:	VP/COO
Name	:	MR. CARLOS VILLAFAN
Credential	:	LPC
Telephone Number	:	710-590-4124

Provider Enumeration Date	:	03/18/2010
Last Update Date	:	03/18/2010

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