Provider Demographics
NPI:1972638245
Name:MIZPAH HEALTHCARE, INC
Entity type:Organization
Organization Name:MIZPAH HEALTHCARE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDREY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:910-848-0694
Mailing Address - Street 1:PO BOX 1796
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28388-1796
Mailing Address - Country:US
Mailing Address - Phone:910-848-0694
Mailing Address - Fax:910-848-0456
Practice Address - Street 1:63 LAKEVIEW DR N
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-8896
Practice Address - Country:US
Practice Address - Phone:828-652-3038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-059-008310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802946Medicaid