Provider Demographics
NPI:1093874455
Name:BETHANY HOME HEALTH OF NACOGDOCHES, INC.
Entity Type:Organization
Organization Name:BETHANY HOME HEALTH OF NACOGDOCHES, INC.
Other - Org Name:BETHANY HOME HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:P
Authorized Official - Last Name:LASSITER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-248-2441
Mailing Address - Street 1:5000 LEGACY DR
Mailing Address - Street 2:SUITE 360
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3100
Mailing Address - Country:US
Mailing Address - Phone:972-248-2441
Mailing Address - Fax:972-248-4347
Practice Address - Street 1:4928 NORTH ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1878
Practice Address - Country:US
Practice Address - Phone:936-569-2949
Practice Address - Fax:936-569-6203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151627001Medicaid
TX679139Medicare Oscar/Certification