Basic Information
| Provider Information | |||||||||
| NPI: | 1053901314 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAVEN SPINE & PAIN CENTER PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2680 LEONARD ST NE STE 3 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495256902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163644200 | ||||||||
| FaxNumber: | 6163647347 | ||||||||
| Practice Location | |||||||||
| Address1: | 2680 LEONARD ST NE STE 3 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495256902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163644200 | ||||||||
| FaxNumber: | 6163647347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2021 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | DILLON | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3125051033 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.