Provider Demographics
NPI:1407931546
Name:GLEN HAVEN HOME, INC.
Entity Type:Organization
Organization Name:GLEN HAVEN HOME, INC.
Other - Org Name:GLEN HAVEN VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARRIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:712-302-9016
Mailing Address - Street 1:252 INDIAN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51534-1912
Mailing Address - Country:US
Mailing Address - Phone:712-302-9016
Mailing Address - Fax:712-302-9017
Practice Address - Street 1:252 INDIAN HILLS DR
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IA
Practice Address - Zip Code:51534-1912
Practice Address - Country:US
Practice Address - Phone:712-302-9016
Practice Address - Fax:712-302-9017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA650355314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0801365Medicaid
IA65530OtherBC BS
IA0801365Medicaid