Provider Demographics
NPI:1053169300
Name:THE HAVEN OF NORTH LITTLE ROCK
Entity type:Organization
Organization Name:THE HAVEN OF NORTH LITTLE ROCK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIRILL
Authorized Official - Middle Name:
Authorized Official - Last Name:VESSELOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-635-2400
Mailing Address - Street 1:2925 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-3000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 SMARTHOUSE WAY
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-5575
Practice Address - Country:US
Practice Address - Phone:561-635-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVEN DETOX LITTLE ROCK, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-10
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder