MEDICARE: PURE HAVEN HOME CARE 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	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1750245452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURE HAVEN HOME CARE LLC

Provider Business Mailing Address
First Line	:	25 CLIFTON AVE APT D2105
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07104-1859
Country	:	US
Telephone Number	:	862-200-7433
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 CLIFTON AVE APT D2105
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07104-1859
Country	:	US
Telephone Number	:	862-200-7433
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	OLUSEGUN OJEWOLE
Credential	:
Telephone Number	:	662-801-5992

Provider Enumeration Date	:	12/16/2025
Last Update Date	:	12/16/2025

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