Basic Information
| Provider Information | |||||||||
| NPI: | 1538676317 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARYHAVEN INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 88 N SANDUSKY ST | ||||||||
| Address2: | |||||||||
| City: | DELAWARE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430151756 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 88 N SANDUSKY ST | ||||||||
| Address2: | |||||||||
| City: | DELAWARE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430151756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402033800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2018 | ||||||||
| LastUpdateDate: | 01/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | HOLT | ||||||||
| AuthorizedOfficialFirstName: | SHAWN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6144458191 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 416832 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) |
No ID Information.