Basic Information
Provider Information
NPI: 1598893778
EntityType: 2
ReplacementNPI:  
OrganizationName: HERMITAGE HOUSE
LastName:  
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Credential:  
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Mailing Information
Address1: 4724 CASTLE HAYNE RD
Address2:  
City: CASTLE HAYNE
State: NC
PostalCode: 284296403
CountryCode: US
TelephoneNumber: 9106752988
FaxNumber:  
Practice Location
Address1: 4724 CASTLE HAYNE RD
Address2:  
City: CASTLE HAYNE
State: NC
PostalCode: 284296403
CountryCode: US
TelephoneNumber: 9106752988
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/01/2007
LastUpdateDate: 08/22/2020
NPIDeactivationReasonCode:  
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ProviderGenderCode:  
AuthorizedOfficialLastName: OSTAPOWICZ
AuthorizedOfficialFirstName: PATTY
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: ADMINISTRATOR
AuthorizedOfficialTelephone: 9106752988
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
310400000XHAL065001NCY Nursing & Custodial Care FacilitiesAssisted Living Facility 

ID Information
IDTypeStateIssuerDescription
780122805NC MEDICAID


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