Provider Demographics
NPI:1588651459
Name:HAVEN HEALTH CENTER OF SOUTH WINDSOR, LLC
Entity Type:Organization
Organization Name:HAVEN HEALTH CENTER OF SOUTH WINDSOR, 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 1:1060 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2407
Mailing Address - Country:US
Mailing Address - Phone:860-289-7771
Mailing Address - Fax:860-289-3761
Practice Address - Street 1:1060 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2407
Practice Address - Country:US
Practice Address - Phone:860-289-7771
Practice Address - Fax:860-289-3761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2271314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT075422Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER