Provider Demographics
NPI:1447788245
Name:BETHESDA FARM
Entity Type:Organization
Organization Name:BETHESDA FARM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:FITZGERALD
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-318-8393
Mailing Address - Street 1:12085 60TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-9761
Mailing Address - Country:US
Mailing Address - Phone:616-318-8393
Mailing Address - Fax:
Practice Address - Street 1:12085 60TH AVE
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401-9761
Practice Address - Country:US
Practice Address - Phone:616-318-8393
Practice Address - Fax:616-318-8393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-24
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services