Provider Demographics
NPI:1487868170
Name:HAVEN BEHAVIORAL SERVICES OF PUEBLO, LLC
Entity Type:Organization
Organization Name:HAVEN BEHAVIORAL SERVICES OF PUEBLO, LLC
Other - Org Name:HAVEN BEHAVIORAL HOSPITAL OF SOUTHERN COLORADO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AVP / REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-393-8816
Mailing Address - Street 1:1008 MINNEQUA AVE
Mailing Address - Street 2:SUITE 6100
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3733
Mailing Address - Country:US
Mailing Address - Phone:719-546-6000
Mailing Address - Fax:719-565-4021
Practice Address - Street 1:1008 MINNEQUA AVE
Practice Address - Street 2:SUITE 6100
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3733
Practice Address - Country:US
Practice Address - Phone:719-546-6000
Practice Address - Fax:719-565-4021
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVEN BEHAVIORAL HEALTHCARE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-10
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPPLIED FOR283Q00000X
CO01P254283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO064025OtherMEDICARE A