Basic Information
| Provider Information | |||||||||
| NPI: | 1952399503 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BETHANY HOME, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BETHANY HOME NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 600 | ||||||||
| Address2: | |||||||||
| City: | MILLEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304420600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789822531 | ||||||||
| FaxNumber: | 4789823131 | ||||||||
| Practice Location | |||||||||
| Address1: | 466 S GRAY ST | ||||||||
| Address2: | |||||||||
| City: | MILLEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304425237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789822531 | ||||||||
| FaxNumber: | 4789823131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | LIVINGSTON | ||||||||
| AuthorizedOfficialFirstName: | BECKY | ||||||||
| AuthorizedOfficialMiddleName: | DASHER | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9127647960 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1-082-014 | GA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00140269A | 05 | GA | MEDICAID |