Basic Information
Provider Information | |||||||||
NPI: | 1568997849 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | W.O.R.C. HAVEN INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9040 SUNSET DR | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331733432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3055969040 | ||||||||
FaxNumber: | 3052753345 | ||||||||
Practice Location | |||||||||
Address1: | 1090 JIMMY ANN DR | ||||||||
Address2: |   | ||||||||
City: | DAYTONA BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 321174591 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3862744228 | ||||||||
FaxNumber: | 3862564874 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2017 | ||||||||
LastUpdateDate: | 04/25/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAVIDSON | ||||||||
AuthorizedOfficialFirstName: | KAREN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER/CFO | ||||||||
AuthorizedOfficialTelephone: | 3052733023 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MACC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X |   |   | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |   |
ID Information
ID | Type | State | Issuer | Description | 140559400 | 05 | FL |   | MEDICAID |