Healthcare Provider Details

I. General information

NPI: 1487995791
Provider Name (Legal Business Name): ROSE HAVEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 6TH ST SE
MENAHGA MN
56464-3157
US

IV. Provider business mailing address

37 6TH ST SE
MENAHGA MN
56464-3157
US

V. Phone/Fax

Practice location:
  • Phone: 218-564-4268
  • Fax: 218-564-5449
Mailing address:
  • Phone: 218-564-4268
  • Fax: 218-564-5449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: RUSSELL EDWAED HENDRICKSON
Title or Position: OWNER
Credential:
Phone: 218-564-4268