Provider Demographics
NPI:1205209004
Name:THE HAVEN DETOX FT. PIERCE, LLC
Entity Type:Organization
Organization Name:THE HAVEN DETOX FT. PIERCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIRILL
Authorized Official - Middle Name:
Authorized Official - Last Name:VESSELOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-616-9000
Mailing Address - Street 1:3951 HAVERHILL RD N
Mailing Address - Street 2:APT 120-121
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33417-8154
Mailing Address - Country:US
Mailing Address - Phone:561-616-9000
Mailing Address - Fax:
Practice Address - Street 1:4707 OLEANDER AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-4209
Practice Address - Country:US
Practice Address - Phone:561-616-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility