Provider Demographics
NPI:1497979959
Name:PRISCILLA C NELSON
Entity Type:Organization
Organization Name:PRISCILLA C NELSON
Other - Org Name:BETHEL HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:BACCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-371-6563
Mailing Address - Street 1:1842 TARA FALLS CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-6570
Mailing Address - Country:US
Mailing Address - Phone:316-440-4406
Mailing Address - Fax:316-201-1015
Practice Address - Street 1:1316 N CHARLOTTE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208
Practice Address - Country:US
Practice Address - Phone:316-440-4406
Practice Address - Fax:316-440-4407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSB087145311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200400780AMedicaid
KS200543750AMedicaid