NPIMap

Organization Active NPI

Haven of Douglas, LLC

  • Skilled Nursing Facility
  • Douglas, AZ
National Provider Identifier
1073850319
Registry record updated May 22, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
NCI-2708 Issued in AZ
Legal business name
HAVEN OF DOUGLAS, LLC
Practice address
1400 N San Antonio Ave
Douglas, AZ 85607-2434
Phone
(520) 364-7937
Fax
(520) 805-9146
NPI assigned
Jan 7, 2013
Last updated
May 22, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
HAVEN HEALTH GROUP ARIZONA, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 22, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Brett P Robertson
Title
President
Phone
(480) 935-4300

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X NCI-2708 AZ Primary
Skilled Nursing Facility 314000000X NU

Addresses

Primary practice location

1400 N San Antonio Ave
Douglas, AZ 85607-2434

Mailing address

1400 N San Antonio Ave
Douglas, AZ 85607-2434
Phone (520) 364-7937

Other identifiers 1

IdentifierTypeStateIssuer
813298MedicaidAZ

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service Other eSolutions Inc.

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130326000043 AZ Part A Provider - Skilled Nursing Facility 6406091313 Practice locations: Douglas, AZ

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1073850319. Details of each certification follow.

Skilled nursing facility certification: CCN 035180

Legal name
HAVEN OF DOUGLAS LLC
Doing business as
HEALTH GROUP MANAGEMENT LLC
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Nov 11, 1988
Last certification
Jul 25, 2024
Beds
60
Ownership / control type
Limited Liability Corporation
Organization structure
LLCProprietary
Enrollment address
1400 N San Antonio Ave
Douglas, AZ 85607-2434
Nursing home name
HAVEN OF DOUGLAS
Affiliated entity
HAVEN HEALTH

Care Compare: Nursing home

Medicare Care Compare
Listed as
Haven of DouglasCCN 035180 · All quality measures
Overall star rating
4 of 5
Health inspections
3 of 5
Staffing
4 of 5
Quality measures
5 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
Nov 11, 1988
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
6055.7 residents per day on average
Chain
Haven Health20 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
03D0874124Haven of Douglas, LLC1400 N San Antonio Ave, Douglas, AZ 85607Certificate of waiverAug 3, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 17

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Adam Brake Individual Operational/Managerial Control Oct 3, 2023
Adp of the SNF Oct 3, 2023
Christian R West Individual 5% Or Greater Indirect Ownership Interest Feb 1, 2013 6.4%
Operational/Managerial Control Feb 1, 2013
Adp of the SNF Feb 1, 2013
Haven Real Estate Partners, LLC Organization, Laguna Beach, CA Adp of the SNF Feb 1, 2013
Parag R Patel Individual Operational/Managerial Control Jan 1, 2023
Adp of the SNF Jan 1, 2023
Haven Arizona Real Estate, LLC Organization, Laguna Beach, CA Adp of the SNF Feb 1, 2013
Stephen Samuelian Individual 5% Or Greater Indirect Ownership Interest Feb 1, 2013 36.73%
Adp of the SNF Feb 1, 2013
Robert Samuelian Individual 5% Or Greater Indirect Ownership Interest Feb 1, 2013 20.13%
Operational/Managerial Control Feb 1, 2013
Adp of the SNF Feb 1, 2013
Spencer R Samuelian Individual 5% Or Greater Indirect Ownership Interest Feb 1, 2013 25.21%
Operational/Managerial Control Feb 1, 2013
Adp of the SNF Feb 1, 2013
Stephanie Espinosa Individual Operational/Managerial Control Oct 14, 2024
Adp of the SNF Oct 14, 2024
Haven Douglas Real Estate LLC Organization, Laguna Beach, CA Adp of the SNF Feb 1, 2013
Mark Muir Individual Operational/Managerial Control Feb 15, 2015
Adp of the SNF Feb 15, 2015
Jason J Seastrand Individual Operational/Managerial Control Feb 1, 2013
Adp of the SNF Feb 1, 2013
Indirect Ownership Interest Feb 1, 2013 3.92%
Lindsay Fragoso Individual Operational/Managerial Control May 10, 2021
Adp of the SNF May 10, 2021
Nina Nelson Individual Operational/Managerial Control Feb 1, 2013
Adp of the SNF Feb 1, 2013
Brett P Robertson Individual 5% Or Greater Indirect Ownership InterestPresident Feb 1, 2013 7.61%
Operational/Managerial Control Feb 1, 2013
Adp of the SNF Feb 1, 2013
Haven Health Group LLC Organization, Laguna Beach, CA Created for acquisition, LLC 5% Or Greater Direct Ownership Interest Feb 1, 2013 100%
Health Group Management LLC Organization, Laguna Beach, CA Management services company Operational/Managerial Control Feb 1, 2013
Adp of the SNF Aug 22, 2025

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 30

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 30

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1357516800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1747872000000",
    "number": "1073850319",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1400 N SAN ANTONIO AVE",
            "city": "DOUGLAS",
            "state": "AZ",
            "postal_code": "856072434",
            "telephone_number": "520-364-7937",
            "fax_number": "520-805-9146"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1400 N SAN ANTONIO AVE",
            "city": "DOUGLAS",
            "state": "AZ",
            "postal_code": "856072434",
            "telephone_number": "520-364-7937",
            "fax_number": "520-805-9146"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HAVEN OF DOUGLAS, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "HAVEN HEALTH GROUP ARIZONA, LLC",
        "enumeration_date": "2013-01-07",
        "last_updated": "2025-05-22",
        "certification_date": "2025-05-22",
        "status": "A",
        "authorized_official_last_name": "ROBERTSON",
        "authorized_official_first_name": "BRETT",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "480-935-4300"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "AZ",
            "license": "NCI-2708",
            "primary": true
        },
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "813298",
            "state": "AZ"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1066.1",
            "affiliationName": "eSolutions Inc.",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "8215 W 108th Ter",
            "city": "Overland Park",
            "state": "KS",
            "country_code": "US",
            "postal_code": "662101661",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Douglas, AZ

Sources for this page

Verify at the official NPI Registry.