Basic Information
| Provider Information | |||||||||
| NPI: | 1235112871 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | S E M HAVEN, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SEM HAVEN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451501009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132481270 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 225 CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451501009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132481270 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEISBRODT | ||||||||
| AuthorizedOfficialFirstName: | ROB | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP IT SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7403824885 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 4228 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0420904 | 05 | OH | MEDICAID |