Basic Information
| Provider Information | |||||||||
| NPI: | 1922368166 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYHAVEN INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1791 ALUM CREEK DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432071708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143245402 | ||||||||
| FaxNumber: | 6148278380 | ||||||||
| Practice Location | |||||||||
| Address1: | 1791 ALUM CREEK DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432071708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143245402 | ||||||||
| FaxNumber: | 6148278380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2012 | ||||||||
| LastUpdateDate: | 10/11/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RITTER | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING/MEDICAL RECORDS ADMINISTRAT | ||||||||
| AuthorizedOfficialTelephone: | 6143245402 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LPCC, LICDC-CS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 1183 | OH | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 2864566 | 05 | OH | MEDICAID |