MEDICARE: MENNO-HAVEN, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	064902	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	064902	OTHER	PA	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639176712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENNO-HAVEN, INC.

Provider Business Mailing Address
First Line	:	2011 SCOTLAND AVE
Second Line	:
City	:	CHAMBERSBURG
State	:	PA
Zip	:	17201-1451
Country	:	US
Telephone Number	:	717-262-1000
Fax Number	:	717-261-0860

Provider Business Practice Location Address
First Line	:	1425 PHILADELPHIA AVE
Second Line	:
City	:	CHAMBERSBURG
State	:	PA
Zip	:	17201-1386
Country	:	US
Telephone Number	:	717-261-0220
Fax Number	:	717-261-1764

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. HUGH DAVIS
Credential	:
Telephone Number	:	717-262-1001

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	04/20/2019

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