Healthcare Provider Details

I. General information

NPI: 1447253661
Provider Name (Legal Business Name): HAVEN HOMES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 04/12/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 WYMAN AVE
MAPLE PLAIN MN
55359-9639
US

IV. Provider business mailing address

4848 GATEWAY BLVD MAPLE PLAIN
MAPLE PLAIN MN
55359
US

V. Phone/Fax

Practice location:
  • Phone: 763-479-1993
  • Fax: 763-479-3656
Mailing address:
  • Phone: 763-292-2300
  • Fax: 763-479-3656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number325307
License Number StateMN

VIII. Authorized Official

Name: SEELOCHANI STADTHERR
Title or Position: SENIOR DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 952-855-5041