Provider Demographics
NPI:1427013655
Name:HENDERSON HAVEN INC
Entity Type:Organization
Organization Name:HENDERSON HAVEN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-264-2522
Mailing Address - Street 1:2554 MOODY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5937
Mailing Address - Country:US
Mailing Address - Phone:904-264-2522
Mailing Address - Fax:904-215-7338
Practice Address - Street 1:2554 MOODY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5937
Practice Address - Country:US
Practice Address - Phone:904-264-2522
Practice Address - Fax:904-215-7338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF001251C00000X, 305S00000X
FLCH17033251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251V00000XAgenciesVoluntary or Charitable
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL683650096Medicaid
FL683650098Medicaid
FLF=========001Medicaid