MEDICARE: MIZPAH NURSING HOME INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	NH2632	VA

General Provider Information

NPI Number	:	1548277734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIZPAH NURSING HOME INC

Provider Business Mailing Address
First Line	:	PO BOX 70
Second Line	:
City	:	LOCUST HILL
State	:	VA
Zip	:	23092-0070
Country	:	US
Telephone Number	:	804-758-5260
Fax Number	:	804-758-0953

Provider Business Practice Location Address
First Line	:	74 MIZPAH ROAD
Second Line	:
City	:	LOCUST HILL
State	:	VA
Zip	:	23092-0070
Country	:	US
Telephone Number	:	804-758-5260
Fax Number	:	804-758-0953

Authorized Official
Title or Position	:	NURSING HOME ADMINISTRATOR
Name	:	MRS. MYRTLE D FAULKNER
Credential	:	LICENSE # 1701000047
Telephone Number	:	804-758-5260

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	08/22/2020

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