Provider Demographics
NPI:1104401322
Name:KORAN WATSON HAVEN OF HEALTH LLC
Entity Type:Organization
Organization Name:KORAN WATSON HAVEN OF HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CEO
Authorized Official - Prefix:
Authorized Official - First Name:KORAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:RDN LDN
Authorized Official - Phone:267-209-3245
Mailing Address - Street 1:21 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4223
Mailing Address - Country:US
Mailing Address - Phone:267-209-3245
Mailing Address - Fax:
Practice Address - Street 1:21 S 11TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4223
Practice Address - Country:US
Practice Address - Phone:267-209-3245
Practice Address - Fax:267-907-8591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-10
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty