Provider Demographics
NPI:1326044322
Name:LUTHERAN HAVEN NURSING HOME AND ASSISTED LIVING FACILITY, LLC
Entity Type:Organization
Organization Name:LUTHERAN HAVEN NURSING HOME AND ASSISTED LIVING FACILITY, LLC
Other - Org Name:LUTHERAN HAVEN NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-365-5676
Mailing Address - Street 1:2041 WEST STATE RD 426
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765
Mailing Address - Country:US
Mailing Address - Phone:407-365-5676
Mailing Address - Fax:407-366-0128
Practice Address - Street 1:1525 HAVEN DRIVE
Practice Address - Street 2:ATTN: NURSING HOME ADMINISTRATOR
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765
Practice Address - Country:US
Practice Address - Phone:407-365-3456
Practice Address - Fax:407-706-1256
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN HAVEN INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-23
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1300096314000000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031371800Medicaid
FL031371800Medicaid
FL031371800Medicaid