Provider Demographics
NPI:1346353497
Name:ROCK HAVEN NURSING HOME, INC.
Entity Type:Organization
Organization Name:ROCK HAVEN NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HOPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-569-9411
Mailing Address - Street 1:401 SE STALLINGS DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75964-7204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:936-569-6511
Practice Address - Street 1:401 SE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75964-7204
Practice Address - Country:US
Practice Address - Phone:936-569-9411
Practice Address - Fax:936-569-6511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117889313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4953Medicaid