1972638245 NPI number — MIZPAH HEALTHCARE, INC

Table of content: (NPI 1972638245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972638245 NPI number — MIZPAH HEALTHCARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIZPAH HEALTHCARE, INC
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:
LAKE JAMES LODGE ASSISTED LIVING
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:
1972638245
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1796
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHERN PINES
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28388-1796
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-848-0694
Provider Business Mailing Address Fax Number:
910-848-0456

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
63 LAKEVIEW DR N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28752-8896
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-652-3038
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHILDREY
Authorized Official First Name:
CATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
910-848-0694

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  HAL-059-008 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7802946 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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