Provider Demographics
NPI:1255769840
Name:HEIDIS HAVEN LLC
Entity type:Organization
Organization Name:HEIDIS HAVEN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-787-3034
Mailing Address - Street 1:1215 LA SALIDA WAY
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-8272
Mailing Address - Country:US
Mailing Address - Phone:352-787-3034
Mailing Address - Fax:352-787-5979
Practice Address - Street 1:1215 LA SALIDA WAY
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-8272
Practice Address - Country:US
Practice Address - Phone:352-787-3034
Practice Address - Fax:352-787-5979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-17
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11848310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility