Provider Demographics
NPI:1336439694
Name:BLUE HAYVEN IN HOME HEALTH CARE LLC
Entity Type:Organization
Organization Name:BLUE HAYVEN IN HOME HEALTH CARE LLC
Other - Org Name:BLUE HAYVEN IN HOME HEALTH CARE LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROCK-WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-440-8087
Mailing Address - Street 1:11553 WITHERSFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63138-1152
Mailing Address - Country:US
Mailing Address - Phone:314-440-8087
Mailing Address - Fax:
Practice Address - Street 1:11553 WITHERSFIELD DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63138-1152
Practice Address - Country:US
Practice Address - Phone:314-440-8087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
302R00000X, 385HR2060X
MO302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child