Provider Demographics
NPI:1497942825
Name:BRITTHAVEN, INC.
Entity Type:Organization
Organization Name:BRITTHAVEN, INC.
Other - Org Name:LAKE PARK NURSING & REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NORWOOD
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:UZZELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-523-9094
Mailing Address - Street 1:PO BOX 2518
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-2518
Mailing Address - Country:US
Mailing Address - Phone:704-882-3420
Mailing Address - Fax:704-882-5197
Practice Address - Street 1:3315 FAITH CHURCH RD
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-9300
Practice Address - Country:US
Practice Address - Phone:704-882-3420
Practice Address - Fax:704-882-5197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0592313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC340613BMedicaid