Provider Demographics
NPI:1730527904
Name:LACI'S HAVEN
Entity type:Organization
Organization Name:LACI'S HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, ADMINISTRATOR, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:573-201-8654
Mailing Address - Street 1:713 SALEM AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3444
Mailing Address - Country:US
Mailing Address - Phone:573-201-8654
Mailing Address - Fax:888-858-8055
Practice Address - Street 1:713 SALEM AVE
Practice Address - Street 2:SUITE E
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3444
Practice Address - Country:US
Practice Address - Phone:573-465-3654
Practice Address - Fax:888-858-8055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-10
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities