Provider Demographics
NPI:1396115234
Name:HAVEN RECOVERY AZ LLC
Entity type:Organization
Organization Name:HAVEN RECOVERY AZ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ERICH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUESCHKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-834-2993
Mailing Address - Street 1:9524 W CAMELBACK RD
Mailing Address - Street 2:STE C-130, #293
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-3104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9524 W CAMELBACK RD
Practice Address - Street 2:STE C-130, #293
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85305-3104
Practice Address - Country:US
Practice Address - Phone:405-834-2993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty