Provider Demographics
NPI:1487648135
Name:BETHANY HOME SOCIETY OF SAN JOAQUIN COUNTY, INC.
Entity Type:Organization
Organization Name:BETHANY HOME SOCIETY OF SAN JOAQUIN COUNTY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-599-4221
Mailing Address - Street 1:930 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-2325
Mailing Address - Country:US
Mailing Address - Phone:209-599-4221
Mailing Address - Fax:209-599-7332
Practice Address - Street 1:930 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:CA
Practice Address - Zip Code:95366-2325
Practice Address - Country:US
Practice Address - Phone:209-599-4221
Practice Address - Fax:209-599-7332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100000015314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05662FMedicaid
CA055662Medicare Oscar/Certification