Provider Demographics
NPI:1790802916
Name:WILLHAVEN RESIDENTIAL COMPLEX, INC.
Entity Type:Organization
Organization Name:WILLHAVEN RESIDENTIAL COMPLEX, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:MR
Authorized Official - First Name:DAIREL
Authorized Official - Middle Name:L
Authorized Official - Last Name:DENTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPA,CFP,CFS,BCM,BCE
Authorized Official - Phone:573-686-3053
Mailing Address - Street 1:PO BOX 1054
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-1054
Mailing Address - Country:US
Mailing Address - Phone:573-686-4700
Mailing Address - Fax:573-686-1441
Practice Address - Street 1:2698 DEBBIE LN
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2629
Practice Address - Country:US
Practice Address - Phone:573-686-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MON00027062320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities