Provider Demographics
NPI:1740895911
Name:ROYAL HAVEN MEDICAL
Entity type:Organization
Organization Name:ROYAL HAVEN MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAIDAMOYO
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGONEKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-400-0433
Mailing Address - Street 1:2384 HIGHWAY 287 N STE 216
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-9207
Mailing Address - Country:US
Mailing Address - Phone:817-400-0433
Mailing Address - Fax:817-415-6595
Practice Address - Street 1:2384 HIGHWAY 287 N STE 216
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9207
Practice Address - Country:US
Practice Address - Phone:817-400-0433
Practice Address - Fax:817-415-6595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-14
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty