Healthcare Provider Details

I. General information

NPI: 1669306775
Provider Name (Legal Business Name): GADDI HAVEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8308 LYNDALE AVE S
BLOOMINGTON MN
55420-2263
US

IV. Provider business mailing address

8308 LYNDALE AVE S
BLOOMINGTON MN
55420-2263
US

V. Phone/Fax

Practice location:
  • Phone: 612-314-9950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: VINCENT MIKAYE
Title or Position: MANAGER
Credential:
Phone: 612-203-7090