Provider Demographics
NPI:1619011830
Name:HAVENS FAMILY CLINIC
Entity Type:Organization
Organization Name:HAVENS FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:719-276-3211
Mailing Address - Street 1:109 LATIGO LN
Mailing Address - Street 2:SUITE C
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-8112
Mailing Address - Country:US
Mailing Address - Phone:719-276-3211
Mailing Address - Fax:
Practice Address - Street 1:109 LATIGO LN
Practice Address - Street 2:SUITE C
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-8112
Practice Address - Country:US
Practice Address - Phone:719-276-3211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28791207Q00000X
CO2124363A00000X
CONP4805363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1205816949OtherINDIVIDUAL NPI NUMBER
CO74402374Medicaid
CO1831176924OtherINDIVIDUAL PROVIDER NPI
CO74402374Medicaid
CO1831176924OtherINDIVIDUAL PROVIDER NPI
COC98044Medicare UPIN
CO000097212Medicare ID - Type Unspecified
CO1205816949OtherINDIVIDUAL NPI NUMBER
CO262018Medicare ID - Type Unspecified