Provider Demographics
NPI:1073673828
Name:BETHESDA LONG TERM CARE, INC.
Entity Type:Organization
Organization Name:BETHESDA LONG TERM CARE, INC.
Other - Org Name:THE CHARLESS HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRINKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-800-1986
Mailing Address - Street 1:4431 SOUTH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63111
Mailing Address - Country:US
Mailing Address - Phone:314-481-4840
Mailing Address - Fax:314-481-1014
Practice Address - Street 1:4431 SOUTH BROADWAY
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63111
Practice Address - Country:US
Practice Address - Phone:314-481-4840
Practice Address - Fax:314-481-1014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO265815Medicare Oscar/Certification