Provider Demographics
NPI:1003958273
Name:HAVEN SUPPORTS, LLC
Entity Type:Organization
Organization Name:HAVEN SUPPORTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-235-0177
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-0299
Mailing Address - Country:US
Mailing Address - Phone:620-235-0177
Mailing Address - Fax:620-235-0177
Practice Address - Street 1:920 E 8TH ST
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-4302
Practice Address - Country:US
Practice Address - Phone:620-235-0177
Practice Address - Fax:620-235-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100401690AMedicaid