Provider Demographics
NPI:1780370544
Name:MIND HAVEN PLLC
Entity type:Organization
Organization Name:MIND HAVEN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:IESHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-BC
Authorized Official - Phone:414-520-7156
Mailing Address - Street 1:479 COOLIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LAVON
Mailing Address - State:TX
Mailing Address - Zip Code:75166-1694
Mailing Address - Country:US
Mailing Address - Phone:414-520-7156
Mailing Address - Fax:
Practice Address - Street 1:479 COOLIDGE LN
Practice Address - Street 2:
Practice Address - City:LAVON
Practice Address - State:TX
Practice Address - Zip Code:75166-1694
Practice Address - Country:US
Practice Address - Phone:414-520-7156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-14
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health