Provider Demographics
NPI:1720460785
Name:HAVENDALE LLC
Entity Type:Organization
Organization Name:HAVENDALE LLC
Other - Org Name:FIRSTLIGHT HOMECARE SOUTHWEST PITTSBURGH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MYKAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUSINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-914-9829
Mailing Address - Street 1:3244 WASHINGTON RD
Mailing Address - Street 2:SUITE 239
Mailing Address - City:MC MURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-6403
Mailing Address - Country:US
Mailing Address - Phone:724-914-8929
Mailing Address - Fax:724-941-4299
Practice Address - Street 1:3244 WASHINGTON RD
Practice Address - Street 2:SUITE 239
Practice Address - City:MC MURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-6403
Practice Address - Country:US
Practice Address - Phone:724-914-8929
Practice Address - Fax:724-941-4299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-25
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA28273601251E00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health