Healthcare Provider Details

I. General information

NPI: 1962531012
Provider Name (Legal Business Name): PINE HAVEN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 3RD ST NW
PINE ISLAND MN
55963-9139
US

IV. Provider business mailing address

210 3RD ST NW
PINE ISLAND MN
55963
US

V. Phone/Fax

Practice location:
  • Phone: 507-356-8304
  • Fax: 507-356-4400
Mailing address:
  • Phone: 507-356-8304
  • Fax: 507-356-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number334206
License Number StateMN

VIII. Authorized Official

Name: STEVE R ZILLER
Title or Position: ADMINISTRATOR / CEO
Credential:
Phone: 507-356-8304