Provider Demographics
NPI:1396214086
Name:DESERT HAVEN
Entity type:Organization
Organization Name:DESERT HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-571-1016
Mailing Address - Street 1:PO BOX 1676
Mailing Address - Street 2:
Mailing Address - City:FAIRACRES
Mailing Address - State:NM
Mailing Address - Zip Code:88033-1676
Mailing Address - Country:US
Mailing Address - Phone:575-571-1016
Mailing Address - Fax:
Practice Address - Street 1:225 E IDAHO AVE STE 25
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3242
Practice Address - Country:US
Practice Address - Phone:575-571-1016
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-26
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251X00000XAgenciesSupports Brokerage
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care FacilityGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Multi-Specialty