Provider Demographics
NPI:1023015138
Name:MENNO HAVEN, INC.
Entity Type:Organization
Organization Name:MENNO HAVEN, INC.
Other - Org Name:BROOKVIEW HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:HUGH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-262-1001
Mailing Address - Street 1:2011 SCOTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-1451
Mailing Address - Country:US
Mailing Address - Phone:717-262-1000
Mailing Address - Fax:717-261-0860
Practice Address - Street 1:2075 SCOTLAND AVE
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1451
Practice Address - Country:US
Practice Address - Phone:717-263-8545
Practice Address - Fax:717-263-6988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA132202314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA132202OtherSTATE LICENSE
PA1000074430005Medicaid
PA1000074430005Medicaid