Healthcare Provider Details

I. General information

NPI: 1942404983
Provider Name (Legal Business Name): MINNESOTA HAVEN HOMES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8227 12TH AVE S
BLOOMINGTON MN
55425-1709
US

IV. Provider business mailing address

8227 12TH AVE S
BLOOMINGTON MN
55425-1709
US

V. Phone/Fax

Practice location:
  • Phone: 612-245-1658
  • Fax: 763-560-1419
Mailing address:
  • Phone: 612-245-1658
  • Fax: 763-560-1419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberR166070-8
License Number StateMN

VIII. Authorized Official

Name: MISS SIA JAMILA SOGBEH
Title or Position: OWNER
Credential: RN
Phone: 612-245-1658