Healthcare Provider Details

I. General information

NPI: 1477867299
Provider Name (Legal Business Name): HAVEN MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 E SAINT CHARLES AVE
FERGUS FALLS MN
56537-3616
US

IV. Provider business mailing address

419 E SAINT CHARLES AVE
FERGUS FALLS MN
56537-3616
US

V. Phone/Fax

Practice location:
  • Phone: 218-739-2799
  • Fax:
Mailing address:
  • Phone: 218-739-2799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number1058161-1-AFC
License Number StateMN

VIII. Authorized Official

Name: CATHY A BELLMORE
Title or Position: MANAGER
Credential:
Phone: 218-739-2799