Provider Demographics
NPI:1598916793
Name:ROYSTER HAVEN
Entity Type:Organization
Organization Name:ROYSTER HAVEN
Other - Org Name:ROYSTER HAVEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:ROMAN
Authorized Official - Last Name:ROYSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-233-6958
Mailing Address - Street 1:2026 OREN AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48505-4688
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2026 OREN AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48505-4688
Practice Address - Country:US
Practice Address - Phone:810-233-6958
Practice Address - Fax:810-235-1048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF250087511320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities