Provider Demographics
NPI:1508839531
Name:HAVEN HEALTH CENTER OF RUTLAND, LLC
Entity Type:Organization
Organization Name:HAVEN HEALTH CENTER OF RUTLAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF AR
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-344-3884
Mailing Address - Street 1:46 NICHOLS ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-3275
Mailing Address - Country:US
Mailing Address - Phone:802-775-2941
Mailing Address - Fax:802-773-2196
Practice Address - Street 1:46 NICHOLS ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-3275
Practice Address - Country:US
Practice Address - Phone:802-775-2941
Practice Address - Fax:802-773-2196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047W089310400000X
VT047W049311Z00000X
VT0475039314000000X
VT475039314000000X
VT047R023385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0475039Medicaid
VT047W089Medicaid
VT047R023Medicaid
VT047W049Medicaid
VT047R023Medicaid