Provider Demographics
NPI:1427152834
Name:HAVEN FAMILY MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:HAVEN FAMILY MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ZAHER
Authorized Official - Middle Name:
Authorized Official - Last Name:AZZAWI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-466-8888
Mailing Address - Street 1:8599 HAVEN AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4849
Mailing Address - Country:US
Mailing Address - Phone:909-466-8888
Mailing Address - Fax:909-483-0164
Practice Address - Street 1:8599 HAVEN AVE
Practice Address - Street 2:STE 101
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4849
Practice Address - Country:US
Practice Address - Phone:909-466-8888
Practice Address - Fax:909-483-0164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA487430305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA487430OtherBLUE CROSS BLUE SHIELD
CA1048460OtherUNITED MPIN
CA1349459OtherUNITED HEALTHCARE GROUP #
CAZZZ02985ZMedicare ID - Type UnspecifiedGROUP NUMBER
CAA487430OtherBLUE CROSS BLUE SHIELD