Provider Demographics
NPI:1245677780
Name:HAVENCREST ALF, LLC
Entity type:Organization
Organization Name:HAVENCREST ALF, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-683-3945
Mailing Address - Street 1:4471 COCONUT CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33066-1742
Mailing Address - Country:US
Mailing Address - Phone:954-971-4289
Mailing Address - Fax:954-345-7123
Practice Address - Street 1:4471 COCONUT CREEK BLVD
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33066-1742
Practice Address - Country:US
Practice Address - Phone:954-971-4289
Practice Address - Fax:954-345-7123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10229310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility