1497135727 NPI number — MIZPAH HEALTHCARE GROUP LLC

Table of content: (NPI 1497135727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497135727 NPI number — MIZPAH HEALTHCARE GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIZPAH HEALTHCARE GROUP LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DOCKSIDE HEALTH & REHAB CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497135727
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23700 COMMERCE PARK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEACHWOOD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44122-5827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-292-5706
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
74 MIZPAH ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOCUST HILL
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-758-5260
Provider Business Practice Location Address Fax Number:
804-758-0953
Provider Enumeration Date:
06/02/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WEISBERG
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
I
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
216-292-5706

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH2632 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1497135727 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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