Provider Demographics
NPI:1851321087
Name:HAVEN OF OUR LADY OF PEACE, INC.
Entity Type:Organization
Organization Name:HAVEN OF OUR LADY OF PEACE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-436-5900
Mailing Address - Street 1:PO BOX 2728
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2728
Mailing Address - Country:US
Mailing Address - Phone:850-416-7070
Mailing Address - Fax:850-416-7453
Practice Address - Street 1:1900 SUMMIT BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-3359
Practice Address - Country:US
Practice Address - Phone:850-436-5900
Practice Address - Fax:850-436-5959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM3XOtherBLUE CROSS OF FLORIDA
FL025883100Medicaid
FLM3XOtherBLUE CROSS OF FLORIDA