Provider Demographics
NPI:1447486808
Name:SIESTA HAVEN
Entity type:Organization
Organization Name:SIESTA HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:C
Authorized Official - Last Name:LAINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-944-6328
Mailing Address - Street 1:PO BOX 3715
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-3715
Mailing Address - Country:US
Mailing Address - Phone:207-944-6328
Mailing Address - Fax:207-942-1204
Practice Address - Street 1:340 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5531
Practice Address - Country:US
Practice Address - Phone:207-944-6328
Practice Address - Fax:207-942-1204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-29
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLA 3411311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home