Provider Demographics
NPI:1417513201
Name:HAVEN IN ALLY LLC
Entity Type:Organization
Organization Name:HAVEN IN ALLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-621-1110
Mailing Address - Street 1:PO BOX 928
Mailing Address - Street 2:
Mailing Address - City:ALLYN
Mailing Address - State:WA
Mailing Address - Zip Code:98524-0928
Mailing Address - Country:US
Mailing Address - Phone:360-277-0636
Mailing Address - Fax:360-275-4021
Practice Address - Street 1:180 E WHEELWRIGHT ST
Practice Address - Street 2:
Practice Address - City:ALLYN
Practice Address - State:WA
Practice Address - Zip Code:98524-8716
Practice Address - Country:US
Practice Address - Phone:360-277-0636
Practice Address - Fax:360-275-4021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility