Provider Demographics
NPI:1477867299
Name:HAVEN MANOR
Entity Type:Organization
Organization Name:HAVEN MANOR
Other - Org Name:BARRETT PRODY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BELLMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-739-2799
Mailing Address - Street 1:419 E SAINT CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-3616
Mailing Address - Country:US
Mailing Address - Phone:218-739-2799
Mailing Address - Fax:
Practice Address - Street 1:419 E SAINT CHARLES AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-3616
Practice Address - Country:US
Practice Address - Phone:218-739-2799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1058161-1-AFC311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1058161-1-AFCOtherMINNESOTA LICENSE