Provider Demographics
NPI:1780765487
Name:BRASK HAVEN INC
Entity type:Organization
Organization Name:BRASK HAVEN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ETTAFA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-448-9940
Mailing Address - Street 1:31274 JULLIARD ST NE
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MN
Mailing Address - Zip Code:55056-6546
Mailing Address - Country:US
Mailing Address - Phone:651-674-7433
Mailing Address - Fax:651-237-0563
Practice Address - Street 1:31274 JULLIARD ST NE
Practice Address - Street 2:
Practice Address - City:NORTH BRANCH
Practice Address - State:MN
Practice Address - Zip Code:55056-6546
Practice Address - Country:US
Practice Address - Phone:651-674-7433
Practice Address - Fax:651-237-0563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN330813310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN216303900OtherMHCP ID