Provider Demographics
NPI:1790060838
Name:STONEHAVEN ASSISTED LIVING INC.
Entity Type:Organization
Organization Name:STONEHAVEN ASSISTED LIVING INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-453-5062
Mailing Address - Street 1:8783 2ND STREET SOUTH
Mailing Address - Street 2:
Mailing Address - City:BROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:55711-0284
Mailing Address - Country:US
Mailing Address - Phone:218-453-5062
Mailing Address - Fax:218-453-5064
Practice Address - Street 1:8783 2ND STREET SOUTH
Practice Address - Street 2:
Practice Address - City:BROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:55711-0284
Practice Address - Country:US
Practice Address - Phone:218-453-5062
Practice Address - Fax:218-453-5064
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STONEHAVEN ASSISTED LIVING INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN354457310400000X
MN35448313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility