Provider Demographics
NPI:1477581544
Name:BETHANY MEDICAL SUPPLY INC.
Entity Type:Organization
Organization Name:BETHANY MEDICAL SUPPLY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:HIBEST
Authorized Official - Middle Name:
Authorized Official - Last Name:ESSAYAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-961-8699
Mailing Address - Street 1:525 N AZUSA AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-4261
Mailing Address - Country:US
Mailing Address - Phone:626-961-8699
Mailing Address - Fax:626-961-8806
Practice Address - Street 1:525 N AZUSA AVE STE 111
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-4261
Practice Address - Country:US
Practice Address - Phone:626-961-8699
Practice Address - Fax:626-961-8806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332B00000X332B00000X
CA103509332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0199939Medicaid
CADME03250FOtherCROSS OVER MEDICAL
CA0199939Medicaid