Provider Demographics
NPI:1073178976
Name:HAVEN OF SEDONA, LLC
Entity type:Organization
Organization Name:HAVEN OF SEDONA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-935-4300
Mailing Address - Street 1:505 JACKS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86351-7856
Mailing Address - Country:US
Mailing Address - Phone:928-284-1000
Mailing Address - Fax:
Practice Address - Street 1:505 JACKS CANYON RD
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86351-7856
Practice Address - Country:US
Practice Address - Phone:928-284-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVEN HEALTH GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-06
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ590852Medicaid