Provider Demographics
NPI:1700863636
Name:BETH SHOLOM HOME OF EASTERN VIRGINIA
Entity Type:Organization
Organization Name:BETH SHOLOM HOME OF EASTERN VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:757-420-2512
Mailing Address - Street 1:6401 AUBURN DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-3601
Mailing Address - Country:US
Mailing Address - Phone:757-420-2512
Mailing Address - Fax:757-424-0657
Practice Address - Street 1:6401 AUBURN DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-3601
Practice Address - Country:US
Practice Address - Phone:757-420-2512
Practice Address - Fax:757-424-0657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-30
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2504314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA215344OtherANTHEM BC/BS
VA4951867Medicaid
VA335333OtherANTHEM FOR DMERC
VA215344OtherANTHEM BC/BS
VA1204850001Medicare NSC
VA215344OtherANTHEM BC/BS