Provider Demographics
NPI:1962531012
Name:PINE HAVEN INC
Entity type:Organization
Organization Name:PINE HAVEN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR / CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:R
Authorized Official - Last Name:ZILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-356-8304
Mailing Address - Street 1:210 3RD ST NW
Mailing Address - Street 2:
Mailing Address - City:PINE ISLAND
Mailing Address - State:MN
Mailing Address - Zip Code:55963
Mailing Address - Country:US
Mailing Address - Phone:507-356-8304
Mailing Address - Fax:507-356-4400
Practice Address - Street 1:210 3RD ST NW
Practice Address - Street 2:
Practice Address - City:PINE ISLAND
Practice Address - State:MN
Practice Address - Zip Code:55963-9139
Practice Address - Country:US
Practice Address - Phone:507-356-8304
Practice Address - Fax:507-356-4400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN334206314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN664240300Medicaid
MN245359OtherMEDICARE
MN8791PIOtherBLUE CROSS BLUE SHIELD