Provider Demographics
NPI:1013034602
Name:SOUTHAVEN INC
Entity Type:Organization
Organization Name:SOUTHAVEN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:STOVERINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-888-9213
Mailing Address - Street 1:612 SOUTH BY-PASS
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857
Mailing Address - Country:US
Mailing Address - Phone:573-888-9213
Mailing Address - Fax:573-888-9218
Practice Address - Street 1:612 SOUTH BY-PASS
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857
Practice Address - Country:US
Practice Address - Phone:573-888-9213
Practice Address - Fax:573-888-9218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO033614310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266179704Medicaid