Provider Demographics
NPI:1518609650
Name:HAVANA MEDICAL AND HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:HAVANA MEDICAL AND HEALTHCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MALIK
Authorized Official - Middle Name:OLASUNKANMI
Authorized Official - Last Name:KUFORIJI
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:720-628-4593
Mailing Address - Street 1:1450 S HAVANA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-4021
Mailing Address - Country:US
Mailing Address - Phone:720-628-4593
Mailing Address - Fax:
Practice Address - Street 1:1450 S HAVANA ST STE 200
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4021
Practice Address - Country:US
Practice Address - Phone:720-628-4593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-09
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO20218235356OtherCERTIFICATE OF GOOD STANDING