Provider Demographics
NPI:1356231765
Name:GRACE HAVEN SOBER LIVING LLC
Entity type:Organization
Organization Name:GRACE HAVEN SOBER LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PEG
Authorized Official - Middle Name:
Authorized Official - Last Name:KINDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-306-8499
Mailing Address - Street 1:1772 PONDEROSA LN
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-6626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1940 REANEY AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-3917
Practice Address - Country:US
Practice Address - Phone:763-415-6301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging