Provider Demographics
NPI:1487995791
Name:ROSE HAVEN
Entity type:Organization
Organization Name:ROSE HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:EDWAED
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-564-4268
Mailing Address - Street 1:37 6TH ST SE
Mailing Address - Street 2:
Mailing Address - City:MENAHGA
Mailing Address - State:MN
Mailing Address - Zip Code:56464-3157
Mailing Address - Country:US
Mailing Address - Phone:218-564-4268
Mailing Address - Fax:218-564-5449
Practice Address - Street 1:37 6TH ST SE
Practice Address - Street 2:
Practice Address - City:MENAHGA
Practice Address - State:MN
Practice Address - Zip Code:56464-3157
Practice Address - Country:US
Practice Address - Phone:218-564-4268
Practice Address - Fax:218-564-5449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient