Provider Demographics
NPI:1881688059
Name:PINE HAVEN CHRISTIAN HOME INC
Entity Type:Organization
Organization Name:PINE HAVEN CHRISTIAN HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-550-5257
Mailing Address - Street 1:531 GIDDINGS AVE
Mailing Address - Street 2:PINE HAVEN CHRISTIAN HOME INC
Mailing Address - City:SHEBOYGAN FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53085-1707
Mailing Address - Country:US
Mailing Address - Phone:920-467-2401
Mailing Address - Fax:920-467-7273
Practice Address - Street 1:220 HAVEN DRIVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN FALLS
Practice Address - State:WI
Practice Address - Zip Code:53085
Practice Address - Country:US
Practice Address - Phone:920-467-2401
Practice Address - Fax:920-467-7273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-02
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI356314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20012000Medicaid
WI20012000Medicaid