Provider Demographics
NPI:1932688223
Name:BETHEL PAVILION HOMECARE LLC
Entity Type:Organization
Organization Name:BETHEL PAVILION HOMECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSEBELLA
Authorized Official - Middle Name:NYABOKE
Authorized Official - Last Name:OGORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-227-7572
Mailing Address - Street 1:7535 DOUGLAS DR N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-2931
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3816 83RD AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-2753
Practice Address - Country:US
Practice Address - Phone:763-227-7572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-08
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility