Provider Demographics
NPI:1245780964
Name:ANGELS' SAFE HAVEN, LLC
Entity Type:Organization
Organization Name:ANGELS' SAFE HAVEN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:HORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-210-6382
Mailing Address - Street 1:P.O. BOX 7206
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374
Mailing Address - Country:US
Mailing Address - Phone:623-210-6382
Mailing Address - Fax:623-440-5939
Practice Address - Street 1:2571 N. 149TH AVE
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395
Practice Address - Country:US
Practice Address - Phone:623-440-4086
Practice Address - Fax:623-440-5939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5019320900000X
322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ207699Medicaid