Provider Demographics
NPI:1528146172
Name:GLEN HAVEN HOME
Entity type:Organization
Organization Name:GLEN HAVEN HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:DELASHMUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-669-9797
Mailing Address - Street 1:700 N LINN ST
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51534-1100
Mailing Address - Country:US
Mailing Address - Phone:712-527-1035
Mailing Address - Fax:712-527-2771
Practice Address - Street 1:700 N LINN ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IA
Practice Address - Zip Code:51534-1100
Practice Address - Country:US
Practice Address - Phone:712-527-1035
Practice Address - Fax:712-527-2771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0191310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0435222Medicaid