Healthcare Provider Details

I. General information

NPI: 1003010125
Provider Name (Legal Business Name): THE HAVEN HALFWAY HOUSE, 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

32524 MEADOW LN
SAINT JOSEPH MN
56374-9760
US

IV. Provider business mailing address

32524 MEADOW LN
SAINT JOSEPH MN
56374-9760
US

V. Phone/Fax

Practice location:
  • Phone: 320-202-7881
  • Fax:
Mailing address:
  • Phone: 320-293-3418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1044351
License Number StateMN

VIII. Authorized Official

Name: MR. THOMAS RUSSELL AUSTAD
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LADC
Phone: 320-293-3418