Provider Demographics
NPI:1467507087
Name:HIGH DESERT HAVEN, INC
Entity Type:Organization
Organization Name:HIGH DESERT HAVEN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-240-9896
Mailing Address - Street 1:PMB 201
Mailing Address - Street 2:20162 HWY 18 STE G
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307
Mailing Address - Country:US
Mailing Address - Phone:760-240-9896
Mailing Address - Fax:760-240-9876
Practice Address - Street 1:20400 ITUMA RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-4445
Practice Address - Country:US
Practice Address - Phone:760-240-9896
Practice Address - Fax:760-240-9876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60936FMedicare ID - Type UnspecifiedINTERMEDIATE CARE FACILIT
CALTC60749FMedicare ID - Type UnspecifiedINTERMIDEATE CARE FACILIT
CALTC60874Medicare ID - Type UnspecifiedINTERMEDIATE CARE FACILIT