Provider Demographics
NPI:1558062059
Name:MISSION HAVEN REDIEMED
Entity Type:Organization
Organization Name:MISSION HAVEN REDIEMED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ABI
Authorized Official - Middle Name:MIKKEL
Authorized Official - Last Name:PROVENCE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-BC, FNP-C
Authorized Official - Phone:817-992-9791
Mailing Address - Street 1:PO BOX 170428
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76003-0428
Mailing Address - Country:US
Mailing Address - Phone:817-435-2812
Mailing Address - Fax:817-719-9236
Practice Address - Street 1:6108 SHOREWOOD DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76016-2649
Practice Address - Country:US
Practice Address - Phone:817-435-2812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty