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General NPI Number Information
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NPI Number | 1518159862
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Entity Type | Organization
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Legal Business Name | BELHAVEN SENIOR CARE
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Dates
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Enumeration Date | 08/10/2007
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Last Update Date | 10/04/2024
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Provider Practice Location Address
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Address Line | 111 KELLY BLVD
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City | MADISON
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State | MS
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Zip | 39110
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Country | US
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Telephone | 601-898-6080
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Fax | 601-898-6348
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Provider Business Mailing Address
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Address Line | 111 KELLY BLVD
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City | MADISON
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State | MS
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Zip | 39110
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Country | US
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Telephone | 601-898-6080
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Fax | 601-898-6348
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MATTHEW CORLEY WAGNER
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Credential | LNHA
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Telephone | 601-898-6080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 624
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License Number State | MS
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