Provider Demographics
NPI:1003862947
Name:BETHESDA, INCORPORATED
Entity Type:Organization
Organization Name:BETHESDA, INCORPORATED
Other - Org Name:THE POTTER'S HEALTHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/DON
Authorized Official - Prefix:
Authorized Official - First Name:KEHINDE
Authorized Official - Middle Name:ROMOKE
Authorized Official - Last Name:AMOSUN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:972-420-0741
Mailing Address - Street 1:873 S STEMMONS FWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-5351
Mailing Address - Country:US
Mailing Address - Phone:972-459-9999
Mailing Address - Fax:972-315-2065
Practice Address - Street 1:873 S STEMMONS FWY STE 100
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-5351
Practice Address - Country:US
Practice Address - Phone:972-459-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX009725251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX453181Medicare ID - Type Unspecified