Provider Demographics
NPI:1922074111
Name:BETHESDA LONG TERM CARE, INC.
Entity Type:Organization
Organization Name:BETHESDA LONG TERM CARE, INC.
Other - Org Name:BETHESDA MEADOW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRINKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-800-1988
Mailing Address - Street 1:1630 DES PERES RD
Mailing Address - Street 2:STE 290
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1800
Mailing Address - Country:US
Mailing Address - Phone:314-800-1900
Mailing Address - Fax:314-800-1961
Practice Address - Street 1:322 OLD STATE RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63021-5917
Practice Address - Country:US
Practice Address - Phone:636-227-3431
Practice Address - Fax:636-394-5037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032050314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO106056609Medicaid
MO106056609Medicaid