MEDICARE: BLESSED HAVEN SC

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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1629831284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLESSED HAVEN SC

Provider Business Mailing Address
First Line	:	2855 JORDAN AVE S APT 209
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55305-3507
Country	:	US
Telephone Number	:	612-598-4075
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 LOGAN AVE N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-1256
Country	:	US
Telephone Number	:	612-598-4075
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BUREEQO O DAHIR
Credential	:
Telephone Number	:	612-598-4075

Provider Enumeration Date	:	02/05/2024
Last Update Date	:	02/05/2024

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Directions to “BLESSED HAVEN SC ” Practice Location

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