Healthcare Provider Details

I. General information

NPI: 1497135727
Provider Name (Legal Business Name): MIZPAH HEALTHCARE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 MIZPAH ROAD
LOCUST HILL VA
23092
US

IV. Provider business mailing address

23700 COMMERCE PARK
BEACHWOOD OH
44122-5827
US

V. Phone/Fax

Practice location:
  • Phone: 804-758-5260
  • Fax: 804-758-0953
Mailing address:
  • Phone: 216-292-5706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH2632
License Number StateVA

VIII. Authorized Official

Name: WILLIAM I WEISBERG
Title or Position: PRESIDENT
Credential:
Phone: 216-292-5706