Provider Demographics
NPI:1669776852
Name:HOLLIS HAVEN LLC
Entity type:Organization
Organization Name:HOLLIS HAVEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:HUFSTEDLER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:417-274-3730
Mailing Address - Street 1:8046 COUNTY ROAD 3010
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-4949
Mailing Address - Country:US
Mailing Address - Phone:417-274-3730
Mailing Address - Fax:417-255-0574
Practice Address - Street 1:8046 COUNTY ROAD 3010
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-4949
Practice Address - Country:US
Practice Address - Phone:417-274-3730
Practice Address - Fax:417-255-0574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-01
Last Update Date:2011-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities