Provider Demographics
NPI:1073375788
Name:GENTLE HAVEN
Entity Type:Organization
Organization Name:GENTLE HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:OMBOI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-913-9934
Mailing Address - Street 1:15768 CARDINAL CIR
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-6613
Mailing Address - Country:US
Mailing Address - Phone:612-913-9934
Mailing Address - Fax:
Practice Address - Street 1:15768 CARDINAL CIR
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-6613
Practice Address - Country:US
Practice Address - Phone:612-913-9934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENTLE HAVEN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility