MEDICARE: HAVEN HOMES, 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	325307	MN

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	:	1447253661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN HOMES, INC.

Provider Business Mailing Address
First Line	:	4848 GATEWAY BLVD
Second Line	:	MAPLE PLAIN
City	:	MAPLE PLAIN
State	:	MN
Zip	:	55359
Country	:	US
Telephone Number	:	763-292-2300
Fax Number	:	763-479-3656

Provider Business Practice Location Address
First Line	:	1520 WYMAN AVE
Second Line	:
City	:	MAPLE PLAIN
State	:	MN
Zip	:	55359-9639
Country	:	US
Telephone Number	:	763-479-1993
Fax Number	:	763-479-3656

Authorized Official
Title or Position	:	SENIOR DIRECTOR OF REIMBURSEMENT
Name	:	SEELOCHANI STADTHERR
Credential	:
Telephone Number	:	952-855-5041

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	04/12/2023

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