Provider Demographics
NPI:1043909310
Name:HAVEN OF HOPE ADULT FAMILY HOME LLC
Entity Type:Organization
Organization Name:HAVEN OF HOPE ADULT FAMILY HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RANDALENE
Authorized Official - Middle Name:NICHOLE
Authorized Official - Last Name:PORCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-926-9243
Mailing Address - Street 1:3474 TULLAMORE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-3019
Mailing Address - Country:US
Mailing Address - Phone:216-926-9243
Mailing Address - Fax:
Practice Address - Street 1:428 E 123RD ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-1704
Practice Address - Country:US
Practice Address - Phone:216-926-9243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home