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General NPI Number Information
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NPI Number | 1013034602
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Entity Type | Organization
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Legal Business Name | SOUTHAVEN INC
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 07/07/2008
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Provider Practice Location Address
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Address Line | 612 SOUTH BY-PASS
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City | KENNETT
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State | MO
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Zip | 63857
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Country | US
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Telephone | 573-888-9213
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Fax | 573-888-9218
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Provider Business Mailing Address
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Address Line | 612 SOUTH BY-PASS
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City | KENNETT
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State | MO
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Zip | 63857
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Country | US
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Telephone | 573-888-9213
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Fax | 573-888-9218
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Authorized Official
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Title or Position | OWNER ADMINISTRATOR
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Name | MRS. GINA DAWN STOVERINK
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Credential |
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Telephone | 573-888-9213
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 033614
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License Number State | MO
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