Provider Demographics
NPI:1447798806
Name:BLUE HAVEN GROUP CORP
Entity Type:Organization
Organization Name:BLUE HAVEN GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:ARIZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-540-6470
Mailing Address - Street 1:3241 NW 108 DR.
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065
Mailing Address - Country:US
Mailing Address - Phone:654-588-1916
Mailing Address - Fax:954-796-7104
Practice Address - Street 1:3241 NW 108TH DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-3528
Practice Address - Country:US
Practice Address - Phone:954-540-6470
Practice Address - Fax:954-796-7104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10-2899GH320600000X
FL10-2794GH320600000X
10-2941GH320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL682933396Medicaid