MEDICARE: PINE HAVEN CHRISTIAN 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	356	WI

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	:	1881688059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE HAVEN CHRISTIAN HOME INC

Provider Business Mailing Address
First Line	:	531 GIDDINGS AVE
Second Line	:	PINE HAVEN CHRISTIAN HOME INC
City	:	SHEBOYGAN FALLS
State	:	WI
Zip	:	53085-1707
Country	:	US
Telephone Number	:	920-467-2401
Fax Number	:	920-467-7273

Provider Business Practice Location Address
First Line	:	220 HAVEN DRIVE
Second Line	:
City	:	SHEBOYGAN FALLS
State	:	WI
Zip	:	53085
Country	:	US
Telephone Number	:	920-467-2401
Fax Number	:	920-467-7273

Authorized Official
Title or Position	:	CFO
Name	:	MARTIN HALVERSON
Credential	:
Telephone Number	:	920-550-5257

Provider Enumeration Date	:	09/02/2005
Last Update Date	:	06/22/2015

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