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General NPI Number Information
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NPI Number | 1811024698
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Entity Type | Organization
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Legal Business Name | SOUTH HAVEN MANOR, INC.
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Dates
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Enumeration Date | 02/27/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 114 NURSING HOME RD
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City | HERTFORD
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State | NC
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Zip | 27944-8879
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Country | US
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Telephone | 434-848-0294
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Fax | 434-848-8302
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Provider Business Mailing Address
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Address Line | 114 NURSING HOME RD
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City | HERTFORD
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State | NC
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Zip | 27944-8879
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Country | US
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Telephone | 434-848-0294
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Fax | 434-848-8302
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Authorized Official
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Title or Position | FISCAL AGENT
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Name | MRS. GRETCHEN GOLDMAN-OWENS
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Credential |
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Telephone | 434-848-0294
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | HAL-072-006
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License Number State | NC
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