Provider Demographics
NPI:1336278365
Name:HAVEN HEALTH CARE MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:HAVEN HEALTH CARE MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NOVA
Authorized Official - Middle Name:C
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-722-9191
Mailing Address - Street 1:502 W STURDIVANT ST
Mailing Address - Street 2:PO BOX 137
Mailing Address - City:ADVANCE
Mailing Address - State:MO
Mailing Address - Zip Code:63730-7261
Mailing Address - Country:US
Mailing Address - Phone:573-722-9191
Mailing Address - Fax:573-722-9393
Practice Address - Street 1:502 W STURDIVANT ST
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:MO
Practice Address - Zip Code:63730-7261
Practice Address - Country:US
Practice Address - Phone:573-722-9191
Practice Address - Fax:573-722-9393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO268934261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO597241306Medicaid
MO597241306Medicaid