Provider Demographics
NPI:1740586940
Name:HAVEN PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:HAVEN PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:417-581-1234
Mailing Address - Street 1:850 N 25TH ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-8033
Mailing Address - Country:US
Mailing Address - Phone:417-581-1234
Mailing Address - Fax:888-844-7031
Practice Address - Street 1:850 N 25TH ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-8033
Practice Address - Country:US
Practice Address - Phone:417-581-1234
Practice Address - Fax:888-550-3518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000150904225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3248Medicare Oscar/Certification