Provider Demographics
NPI:1295733152
Name:HAVEN HOME HEALTH, LLC
Entity type:Organization
Organization Name:HAVEN HOME HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:FUNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-877-0838
Mailing Address - Street 1:5601 EXECUTIVE DR STE 250
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2508
Mailing Address - Country:US
Mailing Address - Phone:972-677-3499
Mailing Address - Fax:
Practice Address - Street 1:5601 EXECUTIVE DR STE 250A
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2508
Practice Address - Country:US
Practice Address - Phone:972-644-3000
Practice Address - Fax:972-644-3040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008425251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159926801Medicaid
TX45D1010398OtherCLIA LAB WAIVER
TX008425OtherTX HOME HEALTH LICENSE
TX45D1010398OtherCLIA LAB WAIVER