Provider Demographics
NPI:1083384838
Name:A BETHEL LOVING CARE OF THE TREASURE COAST
Entity Type:Organization
Organization Name:A BETHEL LOVING CARE OF THE TREASURE COAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARMAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON WALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-353-5535
Mailing Address - Street 1:6136 SUGAR LOAF LN
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-6414
Mailing Address - Country:US
Mailing Address - Phone:561-667-0050
Mailing Address - Fax:772-673-0885
Practice Address - Street 1:1816 SW BRISBANE ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-3507
Practice Address - Country:US
Practice Address - Phone:772-353-5535
Practice Address - Fax:772-673-0885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL13156OtherLICENSE NUMBER