Provider Demographics
NPI:1447657994
Name:HAVEN OF LAKESIDE, LLC
Entity type:Organization
Organization Name:HAVEN OF LAKESIDE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-935-4300
Mailing Address - Street 1:3401 LOCKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5613
Mailing Address - Country:US
Mailing Address - Phone:801-296-5100
Mailing Address - Fax:
Practice Address - Street 1:3401 LOCKWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5613
Practice Address - Country:US
Practice Address - Phone:801-296-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVEN HEALTH GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-28
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ048299Medicaid
AZ035277Medicare Oscar/Certification