=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487789772
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIZPAH HEALTHCARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 74 LOTUS LN
-----------------------------------------------------
City | HENDERSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28792-7058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-692-2220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1796
-----------------------------------------------------
City | SOUTHERN PINES
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28388-1796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-848-0694
-----------------------------------------------------
Fax | 910-848-0456
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. CATHY CHILDREY
-----------------------------------------------------
Credential | R.N.
-----------------------------------------------------
Telephone | 910-848-0694
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | HAL-045-014
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------