Provider Demographics
NPI:1518121128
Name:BLUE HAYVEN FOUNDATION
Entity Type:Organization
Organization Name:BLUE HAYVEN FOUNDATION
Other - Org Name:NONE AT THIS TIME
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:MICHEELE
Authorized Official - Last Name:BROCK-WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-440-8087
Mailing Address - Street 1:36 JULIE LN
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-2147
Mailing Address - Country:US
Mailing Address - Phone:314-440-8087
Mailing Address - Fax:314-395-6121
Practice Address - Street 1:36 JULIE LN
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2147
Practice Address - Country:US
Practice Address - Phone:314-440-8087
Practice Address - Fax:314-395-6121
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE HAYVEN FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-12
Last Update Date:2008-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities