Basic Information
| Provider Information | |||||||||
| NPI: | 1821057100 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BETHANY HOME, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BETHANY NURSING CENTER OF VIDALIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1305 EAST NORTH ST | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125377922 | ||||||||
| FaxNumber: | 9125370216 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 EAST NORTH ST | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125377922 | ||||||||
| FaxNumber: | 9125370216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 01/13/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WINGE | ||||||||
| AuthorizedOfficialFirstName: | SHARRON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9125377922 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1138015 | GA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00140258B | 05 | GA | MEDICAID | 00140258A | 05 | GA | MEDICAID |