Provider Demographics
NPI:1437826211
Name:HAVEN MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:HAVEN MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTICE
Authorized Official - Middle Name:
Authorized Official - Last Name:OTCHERE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:682-433-9287
Mailing Address - Street 1:1332 W HERNDON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-7118
Mailing Address - Country:US
Mailing Address - Phone:682-433-9287
Mailing Address - Fax:
Practice Address - Street 1:1332 W HERNDON AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-7118
Practice Address - Country:US
Practice Address - Phone:682-433-9287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty