Healthcare Provider Details

I. General information

NPI: 1255789491
Provider Name (Legal Business Name): HAVEN NURSING HOME, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 05/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 PENHURST AVE
BALTIMORE MD
21215-5632
US

IV. Provider business mailing address

3939 PENHURST AVE
BALTIMORE MD
21215-5632
US

V. Phone/Fax

Practice location:
  • Phone: 410-664-9535
  • Fax:
Mailing address:
  • Phone: 410-664-9535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number30074
License Number StateMD

VIII. Authorized Official

Name: MR. DAREN CORTESE
Title or Position: PRESIDENT
Credential:
Phone: 410-560-4925