Provider Demographics
NPI:1720506926
Name:HAVEN OF SIERRA VISTA, LLC
Entity type:Organization
Organization Name:HAVEN OF SIERRA VISTA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
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 1:660 S CORONADO DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-3386
Mailing Address - Country:US
Mailing Address - Phone:520-459-4900
Mailing Address - Fax:801-296-5111
Practice Address - Street 1:660 S CORONADO DR
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-3386
Practice Address - Country:US
Practice Address - Phone:520-459-4900
Practice Address - Fax:801-296-5111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVEN HEALTH GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-07
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
AZ432588Medicaid