Basic Information
| Provider Information | |||||||||
| NPI: | 1043207723 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAVEN HEALTH CENTER OF NEW HAVEN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 ELLA T GRASSO BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065195516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038655155 | ||||||||
| FaxNumber: | 2038654186 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 ELLA T GRASSO BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065195516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038655155 | ||||||||
| FaxNumber: | 2038654186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 12/28/2007 | ||||||||
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| AuthorizedOfficialLastName: | BLOOM | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF AR | ||||||||
| AuthorizedOfficialTelephone: | 8603443884 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2099588000 | CT | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 296 | 01 | CT | BLUE CROSS BLUE SHIELD | OTHER |