MEDICARE: SOUTHHAVEN ENTERPRISES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	4917	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235237462
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHHAVEN ENTERPRISES, LLC

Provider Business Mailing Address
First Line	:	5300 HOUSTON SCHOOL RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75241-1219
Country	:	US
Telephone Number	:	214-372-1496
Fax Number	:	214-374-7333

Provider Business Practice Location Address
First Line	:	5300 HOUSTON SCHOOL RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75241-1219
Country	:	US
Telephone Number	:	214-372-1496
Fax Number	:	214-374-7333

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. DEE BATES
Credential	:
Telephone Number	:	940-864-3619

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	10/07/2008

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