1356520233 NPI number — BETHANY HOME HEALTH OF LAKE JACKSON LP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356520233 NPI number — BETHANY HOME HEALTH OF LAKE JACKSON LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BETHANY HOME HEALTH OF LAKE JACKSON LP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356520233
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 THAT WAY ST
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
LAKE JACKSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77566-5211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-297-1414
Provider Business Mailing Address Fax Number:
979-297-1818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18333 PRESTON RD
Provider Second Line Business Practice Location Address:
SUITE 410
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75252-5466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-248-2441
Provider Business Practice Location Address Fax Number:
972-248-0773
Provider Enumeration Date:
10/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LASSITER
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
972-248-2441

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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