Healthcare Provider Details

I. General information

NPI: 1669507919
Provider Name (Legal Business Name): MIZPAH HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 BANNER AVE
GREENSBORO NC
27401-4303
US

IV. Provider business mailing address

PO BOX 1796
SOUTHERN PINES NC
28388-1796
US

V. Phone/Fax

Practice location:
  • Phone: 336-273-2380
  • Fax:
Mailing address:
  • Phone: 910-848-0694
  • Fax: 910-848-0456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberHAL-041-019
License Number StateNC

VIII. Authorized Official

Name: MS. CATHY CHILDREY
Title or Position: CEO
Credential: R.N.
Phone: 910-848-0694