Provider Demographics
NPI:1265845499
Name:THE HAVEN HOME
Entity Type:Organization
Organization Name:THE HAVEN HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SCHNIKWA
Authorized Official - Middle Name:LAS
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:NA
Authorized Official - Phone:469-734-7674
Mailing Address - Street 1:1216 HOLT AVE
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-3110
Mailing Address - Country:US
Mailing Address - Phone:972-803-5605
Mailing Address - Fax:972-803-5605
Practice Address - Street 1:1216 HOLT AVE
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-3110
Practice Address - Country:US
Practice Address - Phone:972-803-5605
Practice Address - Fax:972-803-5605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX139524302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization