Provider Demographics
NPI:1568042513
Name:HAVENLIGHT PLLC
Entity Type:Organization
Organization Name:HAVENLIGHT PLLC
Other - Org Name:HAVENLIGHT HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:REESER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-396-5623
Mailing Address - Street 1:809 W RIORDAN RD STE 100-132
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-0842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7160 E KIERLAND BLVD
Practice Address - Street 2:STE 213
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-2987
Practice Address - Country:US
Practice Address - Phone:623-396-5623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-13
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ257365Medicaid