Provider Demographics
NPI:1770007908
Name:REST HAVEN MANAGEMENT INC. FOURSEE '4C'
Entity Type:Organization
Organization Name:REST HAVEN MANAGEMENT INC. FOURSEE '4C'
Other - Org Name:FOURSEE '4C'
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTOR/BUSINESS OPERATION MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ENETRICE
Authorized Official - Middle Name:RENNE
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:AS, BBA, MBA
Authorized Official - Phone:317-919-2923
Mailing Address - Street 1:368015 OLD HIGHWAY 62
Mailing Address - Street 2:
Mailing Address - City:BOLEY
Mailing Address - State:OK
Mailing Address - Zip Code:74829-2914
Mailing Address - Country:US
Mailing Address - Phone:918-667-3372
Mailing Address - Fax:
Practice Address - Street 1:368015 OLD HIGHWAY 62
Practice Address - Street 2:
Practice Address - City:BOLEY
Practice Address - State:OK
Practice Address - Zip Code:74829-2914
Practice Address - Country:US
Practice Address - Phone:918-667-3372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities