Provider Demographics
NPI: | 1467919399 |
---|---|
Name: | UNICORN HAVEN LLC |
Entity Type: | Organization |
Organization Name: | UNICORN HAVEN LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | BARBORA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | HLADEK |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 602-909-3223 |
Mailing Address - Street 1: | 1445 E GUADALUPE RD STE 109 |
Mailing Address - Street 2: | |
Mailing Address - City: | TEMPE |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85283-3953 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 602-909-3223 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1445 E GUADALUPE RD STE 109 |
Practice Address - Street 2: | |
Practice Address - City: | TEMPE |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85283-3953 |
Practice Address - Country: | US |
Practice Address - Phone: | 602-909-3223 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2019-02-27 |
Last Update Date: | 2019-02-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 385HR2060X | Respite Care Facility | Respite Care | Respite Care, Intellectual and/or Developmental Disabilities, Child |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
465505 | Other | AHCCCS |