Provider Demographics
NPI:1235237462
Name:SOUTHHAVEN ENTERPRISES, LLC
Entity Type:Organization
Organization Name:SOUTHHAVEN ENTERPRISES, LLC
Other - Org Name:SOUTHAVEN NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-864-3619
Mailing Address - Street 1:5300 HOUSTON SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75241-1219
Mailing Address - Country:US
Mailing Address - Phone:214-372-1496
Mailing Address - Fax:214-374-7333
Practice Address - Street 1:5300 HOUSTON SCHOOL RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75241-1219
Practice Address - Country:US
Practice Address - Phone:214-372-1496
Practice Address - Fax:214-374-7333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4917313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001012292Medicaid
TX001012292Medicaid