Provider Demographics
NPI:1548277734
Name:MIZPAH NURSING HOME INC
Entity type:Organization
Organization Name:MIZPAH NURSING HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSING HOME ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYRTLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSE # 1701000047
Authorized Official - Phone:804-758-5260
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:LOCUST HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23092-0070
Mailing Address - Country:US
Mailing Address - Phone:804-758-5260
Mailing Address - Fax:804-758-0953
Practice Address - Street 1:74 MIZPAH ROAD
Practice Address - Street 2:
Practice Address - City:LOCUST HILL
Practice Address - State:VA
Practice Address - Zip Code:23092-0070
Practice Address - Country:US
Practice Address - Phone:804-758-5260
Practice Address - Fax:804-758-0953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2632313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility