MEDICARE: GADDI HAVEN LLC

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1669306775
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GADDI HAVEN LLC

Provider Business Mailing Address
First Line	:	8308 LYNDALE AVE S
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55420-2263
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8308 LYNDALE AVE S
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55420-2263
Country	:	US
Telephone Number	:	612-314-9950
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	VINCENT MIKAYE
Credential	:
Telephone Number	:	612-203-7090

Provider Enumeration Date	:	06/12/2026
Last Update Date	:	06/12/2026

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