Provider Demographics
NPI:1053901314
Name:HAVEN SPINE & PAIN CENTER PLLC
Entity type:Organization
Organization Name:HAVEN SPINE & PAIN CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-505-1033
Mailing Address - Street 1:2680 LEONARD ST NE STE 3
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6902
Mailing Address - Country:US
Mailing Address - Phone:616-364-4200
Mailing Address - Fax:616-364-7347
Practice Address - Street 1:2680 LEONARD ST NE STE 3
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6902
Practice Address - Country:US
Practice Address - Phone:616-364-4200
Practice Address - Fax:616-364-7347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-21
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty