Provider Demographics
NPI:1033882220
Name:MACE, BETHANY (TYPE 55)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:MACE
Suffix:
Gender:F
Credentials:TYPE 55
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 ELLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45431-1936
Mailing Address - Country:US
Mailing Address - Phone:937-250-9767
Mailing Address - Fax:
Practice Address - Street 1:119 ELLINGTON RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45431-1936
Practice Address - Country:US
Practice Address - Phone:937-250-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRJ462621343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)