Provider Demographics
NPI:1265779516
Name:HAVEN OF SHOW LOW, LLC
Entity type:Organization
Organization Name:HAVEN OF SHOW LOW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:P
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-935-4300
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:928-537-1762
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:928-537-1762
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVEN HEALTH GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-07
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X
AZNCI-2704314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ813272Medicaid
AZ813272Medicaid