Provider Demographics
NPI:1043823701
Name:MOTHER HARRELL'S HAVEN
Entity type:Organization
Organization Name:MOTHER HARRELL'S HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-268-9065
Mailing Address - Street 1:1603 25TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-3421
Mailing Address - Country:US
Mailing Address - Phone:330-268-9065
Mailing Address - Fax:
Practice Address - Street 1:1603 25TH ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-3421
Practice Address - Country:US
Practice Address - Phone:330-268-9065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health