Provider Demographics
NPI:1588901839
Name:HAVEN OF FLAGSTAFF, LLC
Entity type:Organization
Organization Name:HAVEN OF FLAGSTAFF, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:P
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-935-4300
Mailing Address - Street 1:800 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-7103
Mailing Address - Country:US
Mailing Address - Phone:928-779-6931
Mailing Address - Fax:892-877-9218
Practice Address - Street 1:800 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7103
Practice Address - Country:US
Practice Address - Phone:928-779-6931
Practice Address - Fax:892-877-9218
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVEN HEALTH GROUP ARIZONA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-07
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X
AZNCI-2662314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ813243Medicaid
AZ035091Medicare Oscar/Certification