Provider Demographics
NPI:1245479401
Name:SAFE HAVENS OF KORNERSTONE
Entity type:Organization
Organization Name:SAFE HAVENS OF KORNERSTONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:H
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-276-9009
Mailing Address - Street 1:3221 W PIONEER PKWY
Mailing Address - Street 2:
Mailing Address - City:PANTEGO
Mailing Address - State:TX
Mailing Address - Zip Code:76013-4620
Mailing Address - Country:US
Mailing Address - Phone:817-276-9009
Mailing Address - Fax:817-276-9084
Practice Address - Street 1:3221 W PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:PANTEGO
Practice Address - State:TX
Practice Address - Zip Code:76013-4620
Practice Address - Country:US
Practice Address - Phone:817-276-9009
Practice Address - Fax:817-276-9084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX854064-424253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency