Provider Demographics
NPI:1275125973
Name:HEALTHY HAVEN GROUP HOME LLC
Entity Type:Organization
Organization Name:HEALTHY HAVEN GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:HASHANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-403-8296
Mailing Address - Street 1:8761 N 56TH ST UNIT 292024
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33687-9180
Mailing Address - Country:US
Mailing Address - Phone:813-403-8296
Mailing Address - Fax:
Practice Address - Street 1:11350 66TH ST STE 104
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-5524
Practice Address - Country:US
Practice Address - Phone:813-403-8296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities