MEDICARE: REST HAVEN HEALTH CARE CENTER, LLC

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	0965	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912995069
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REST HAVEN HEALTH CARE CENTER, LLC

Provider Business Mailing Address
First Line	:	7672 W MINERAL POINT RD
Second Line	:
City	:	VERONA
State	:	WI
Zip	:	53593-9668
Country	:	US
Telephone Number	:	608-833-1691
Fax Number	:	608-833-0492

Provider Business Practice Location Address
First Line	:	7672 W MINERAL POINT RD
Second Line	:
City	:	VERONA
State	:	WI
Zip	:	53593-9668
Country	:	US
Telephone Number	:	608-833-1691
Fax Number	:	608-833-0492

Authorized Official
Title or Position	:	OWNER
Name	:	MR. EDWIN M. KRUCHTEN
Credential	:
Telephone Number	:	608-849-5016

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	01/31/2008

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