Provider Demographics
NPI:1265880603
Name:PINE HAVEN OPERATING
Entity type:Organization
Organization Name:PINE HAVEN OPERATING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-641-0303
Mailing Address - Street 1:201 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PHILMONT
Mailing Address - State:NY
Mailing Address - Zip Code:12565
Mailing Address - Country:US
Mailing Address - Phone:518-672-7408
Mailing Address - Fax:
Practice Address - Street 1:201 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PHILMONT
Practice Address - State:NY
Practice Address - Zip Code:12565
Practice Address - Country:US
Practice Address - Phone:518-672-7408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility