Provider Demographics
NPI:1043082555
Name:HAVEN DETOX OF WEST MEMPHIS, LLC
Entity type:Organization
Organization Name:HAVEN DETOX OF WEST MEMPHIS, LLC
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 1:410 S AVALON ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4183
Practice Address - Country:US
Practice Address - Phone:561-635-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility