MEDICARE: HAVEN NURSING HOME, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	30074	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255789491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN NURSING HOME, INC

Provider Business Mailing Address
First Line	:	3939 PENHURST AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-5632
Country	:	US
Telephone Number	:	410-664-9535
Fax Number	:

Provider Business Practice Location Address
First Line	:	3939 PENHURST AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-5632
Country	:	US
Telephone Number	:	410-664-9535
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DAREN CORTESE
Credential	:
Telephone Number	:	410-560-4925

Provider Enumeration Date	:	05/27/2016
Last Update Date	:	05/27/2016

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