Provider Demographics
NPI:1649855917
Name:SOUTH HAVEN OPCO, LLC
Entity type:Organization
Organization Name:SOUTH HAVEN OPCO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OHLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:541-543-1215
Mailing Address - Street 1:7400 NEW LA GRANGE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4870
Mailing Address - Country:US
Mailing Address - Phone:502-429-8062
Mailing Address - Fax:502-429-5980
Practice Address - Street 1:120 BASELINE RD
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-1037
Practice Address - Country:US
Practice Address - Phone:269-637-8411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility