Provider Demographics
NPI:1114974243
Name:PARK HAVEN INC
Entity Type:Organization
Organization Name:PARK HAVEN INC
Other - Org Name:PARK HAVEN HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEATRICE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KNOWLSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN/LNHA
Authorized Official - Phone:440-992-8387
Mailing Address - Street 1:2125 W PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-6439
Mailing Address - Country:US
Mailing Address - Phone:440-992-8387
Mailing Address - Fax:440-992-7650
Practice Address - Street 1:4533 PARK AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-6930
Practice Address - Country:US
Practice Address - Phone:440-992-9441
Practice Address - Fax:440-992-7592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6091313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0242553Medicaid
OH366056Medicare ID - Type UnspecifiedMEDICARE PROVIDER #