Provider Demographics
NPI:1114461464
Name:SENIOR HAVEN HOME CARE
Entity Type:Organization
Organization Name:SENIOR HAVEN HOME CARE
Other - Org Name:HOME INSTEAD SENIOR CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:563-599-7674
Mailing Address - Street 1:513 PINE LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-2316
Mailing Address - Country:US
Mailing Address - Phone:219-326-1082
Mailing Address - Fax:219-326-1413
Practice Address - Street 1:513 PINE LAKE AVE
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-2316
Practice Address - Country:US
Practice Address - Phone:219-326-1082
Practice Address - Fax:219-326-1413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INIC 16-27-4251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201364430OtherMEDICAID LPI
INIC-16-27-4OtherPERSONAL SERVICES AGENCY LICENSE