Basic Information
| Provider Information | |||||||||
| NPI: | 1295733152 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAVEN HOME HEALTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5601 EXECUTIVE DR STE 250 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750382508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9726773499 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1221 ABRAMS RD STE 109 | ||||||||
| Address2: | |||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750815598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9726443000 | ||||||||
| FaxNumber: | 9726443040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | FUNSTON | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | GEORGE | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7068770838 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 008425 | TX | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 45D1010398 | 01 | TX | CLIA LAB WAIVER | OTHER | 159926801 | 05 | TX | MEDICAID |