Basic Information
| Provider Information | |||||||||
| NPI: | 1699962027 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRITTHAVEN, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRITTHAVEN OF CHARLOTTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 561869 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282561869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045490807 | ||||||||
| FaxNumber: | 7045488413 | ||||||||
| Practice Location | |||||||||
| Address1: | 9200 GLENWATER DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282628557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045490807 | ||||||||
| FaxNumber: | 7045488413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 10/01/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | UZZELL | ||||||||
| AuthorizedOfficialFirstName: | NORWOOD | ||||||||
| AuthorizedOfficialMiddleName: | RANDOLPH | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2525239094 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH0016 | NC | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 3406474 | 05 | NC | MEDICAID |