Provider Demographics
NPI:1215919949
Name:THOMAS REST HAVEN
Entity type:Organization
Organization Name:THOMAS REST HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:VENTEICHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-999-2253
Mailing Address - Street 1:217 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:50058-1605
Mailing Address - Country:US
Mailing Address - Phone:712-999-2253
Mailing Address - Fax:712-999-5669
Practice Address - Street 1:217 MAIN ST
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:50058-1605
Practice Address - Country:US
Practice Address - Phone:712-999-2253
Practice Address - Fax:712-999-5669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA140430261QR0400X, 313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA65358OtherWELLMARK
IA0803973Medicaid
IA0803973Medicaid