Provider Demographics
NPI:1073508883
Name:OUR LADY'S HAVEN OF FAIRHAVEN, INC.
Entity type:Organization
Organization Name:OUR LADY'S HAVEN OF FAIRHAVEN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-679-8154
Mailing Address - Street 1:71 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-3822
Mailing Address - Country:US
Mailing Address - Phone:508-999-4561
Mailing Address - Fax:508-997-0254
Practice Address - Street 1:71 CENTER ST
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-3822
Practice Address - Country:US
Practice Address - Phone:508-999-4561
Practice Address - Fax:508-997-0254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA887314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0904929Medicaid
MA225485Medicare ID - Type Unspecified