| Blk Haven Corp. | |
|
1079 Calle Deceo Chula Vista CA 91913-3345 | |
| (763) 245-0390 | |
| Not Available |
| Full Name | Blk Haven Corp. |
|---|---|
| Speciality | Counselor |
| Location | 1079 Calle Deceo, Chula Vista, California |
| Authorized Official Name and Position | Ashlee S Wilson (CEO/ CO-FOUNDER) |
| Authorized Official Contact | 7632450390 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Blk Haven Corp. 718 Kikanai Loop Honolulu HI 96818-4434 Ph: (763) 245-0390 | Blk Haven Corp. 1079 Calle Deceo Chula Vista CA 91913-3345 Ph: (763) 245-0390 |
| NPI Number | 1942936620 |
|---|---|
| Provider Enumeration Date | 07/26/2022 |
| Last Update Date | 07/26/2022 |
| Certification Date | 07/26/2022 |
| Medicare PECOS PAC ID | 5890169833 |
|---|---|
| Medicare Enrollment ID | O20230315000413 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1942936620 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| Provider Name | Kendra Butler |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1861139081 PECOS PAC ID: 1355722430 Enrollment ID: I20230315001377 |
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