Provider Demographics
NPI:1407100514
Name:HOPE HAVEN REBOS UNITED INC
Entity Type:Organization
Organization Name:HOPE HAVEN REBOS UNITED INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MSCSAC,ICS
Authorized Official - Phone:608-441-0204
Mailing Address - Street 1:810 W OLIN AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-2142
Mailing Address - Country:US
Mailing Address - Phone:608-255-5922
Mailing Address - Fax:608-255-0340
Practice Address - Street 1:810 W OLIN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-2142
Practice Address - Country:US
Practice Address - Phone:608-255-5922
Practice Address - Fax:608-255-0340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1774320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1417112780Medicaid