Basic Information
| Provider Information | |||||||||
| NPI: | 1508839531 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAVEN HEALTH CENTER OF RUTLAND, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 46 NICHOLS ST | ||||||||
| Address2: | |||||||||
| City: | RUTLAND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057013275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027752941 | ||||||||
| FaxNumber: | 8027732196 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 NICHOLS ST | ||||||||
| Address2: | |||||||||
| City: | RUTLAND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057013275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027752941 | ||||||||
| FaxNumber: | 8027732196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| 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 | 0475039 | VT | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 310400000X | 047W089 | VT | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 311Z00000X | 047W049 | VT | N | Nursing & Custodial Care Facilities | Custodial Care Facility | 385H00000X | 047R023 | VT | N | Respite Care Facility | Respite Care | 314000000X | 475039 | VT | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0475039 | 05 | VT | MEDICAID | 047W089 | 05 | VT | MEDICAID | 047R023 | 05 | VT | MEDICAID | 047W049 | 05 | VT | MEDICAID |