Provider Demographics
NPI:1881194629
Name:HAVEN OF SHOW LOW ALF LLC
Entity Type:Organization
Organization Name:HAVEN OF SHOW LOW ALF LLC
Other - Org Name:HAVEN OF SHOW LOW ALF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-296-5100
Mailing Address - Street 1:2401 E HUNT DR
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7920
Mailing Address - Country:US
Mailing Address - Phone:928-537-5333
Mailing Address - Fax:
Practice Address - Street 1:2401 E HUNT DR
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7920
Practice Address - Country:US
Practice Address - Phone:928-537-5333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-19
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ463487Medicaid