Provider Demographics
NPI:1114972627
Name:HAVEN PHYSICAL THERAPY
Entity Type:Organization
Organization Name:HAVEN PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:BOEKHOUT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:909-481-5304
Mailing Address - Street 1:7974 HAVEN AVE
Mailing Address - Street 2:SUITE 290
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3061
Mailing Address - Country:US
Mailing Address - Phone:909-481-5304
Mailing Address - Fax:909-481-5307
Practice Address - Street 1:7974 HAVEN AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3061
Practice Address - Country:US
Practice Address - Phone:909-481-5304
Practice Address - Fax:909-481-5307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy