Provider Demographics
NPI:1679810915
Name:HAVEN OF COTTONWOOD, LLC
Entity type:Organization
Organization Name:HAVEN OF COTTONWOOD, 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 1:197 S WILLARD ST
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4123
Mailing Address - Country:US
Mailing Address - Phone:928-634-5548
Mailing Address - Fax:928-634-9602
Practice Address - Street 1:197 S WILLARD ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4123
Practice Address - Country:US
Practice Address - Phone:928-634-5548
Practice Address - Fax:928-634-9602
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVEN HEALTH GROUP 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
AZNCI-2707314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ813280Medicaid
AZ813280Medicaid