Provider Demographics
NPI:1407396393
Name:HAVEN PHYSICAL THERAPY
Entity Type:Organization
Organization Name:HAVEN PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:417-581-1234
Mailing Address - Street 1:850 N 25TH ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-9164
Mailing Address - Country:US
Mailing Address - Phone:417-581-1234
Mailing Address - Fax:
Practice Address - Street 1:1114 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-9164
Practice Address - Country:US
Practice Address - Phone:417-581-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-27
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORO570251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1740586940Medicaid
MO1740586940Medicaid
MOMA3248Medicare UPIN