Provider Demographics
NPI:1952387243
Name:HAVEN MEDICAL SUPPLY
Entity Type:Organization
Organization Name:HAVEN MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE/ AR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:DONALIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-649-9809
Mailing Address - Street 1:7726 US HWY 165
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:LA
Mailing Address - Zip Code:71418-7726
Mailing Address - Country:US
Mailing Address - Phone:318-649-9809
Mailing Address - Fax:318-649-9825
Practice Address - Street 1:7726 US HWY 165
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:LA
Practice Address - Zip Code:71418-7726
Practice Address - Country:US
Practice Address - Phone:318-649-9809
Practice Address - Fax:318-649-9825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010703002000332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1382655Medicaid
LA75YP31701Medicare UPIN
LA0286930001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER