=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548277734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIZPAH NURSING HOME INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 74 MIZPAH ROAD
-----------------------------------------------------
City | LOCUST HILL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23092-0070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-758-5260
-----------------------------------------------------
Fax | 804-758-0953
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 70
-----------------------------------------------------
City | LOCUST HILL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23092-0070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-758-5260
-----------------------------------------------------
Fax | 804-758-0953
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSING HOME ADMINISTRATOR
-----------------------------------------------------
Name | MRS. MYRTLE D FAULKNER
-----------------------------------------------------
Credential | LICENSE # 1701000047
-----------------------------------------------------
Telephone | 804-758-5260
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | NH2632
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------