Provider Demographics
NPI:1952323123
Name:BETHESTA HOME HEALTH CARE, LLC
Entity Type:Organization
Organization Name:BETHESTA HOME HEALTH CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-344-5492
Mailing Address - Street 1:2500 NW 79TH AVE STE 271
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33122-1089
Mailing Address - Country:US
Mailing Address - Phone:305-629-6426
Mailing Address - Fax:305-629-6426
Practice Address - Street 1:2500 NW 79TH AVE STE 120
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33122-1031
Practice Address - Country:US
Practice Address - Phone:305-629-6425
Practice Address - Fax:305-629-6426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL299992294251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL651305100Medicaid
FL651305100Medicaid