Provider Demographics
NPI:1962627851
Name:BETHANNA
Entity Type:Organization
Organization Name:BETHANNA
Other - Org Name:BETHANNA BIBLE AND MISSIONARY CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:FRITCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-355-6500
Mailing Address - Street 1:1030 2ND STREET PIKE
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3955
Mailing Address - Country:US
Mailing Address - Phone:215-355-6500
Mailing Address - Fax:215-355-8617
Practice Address - Street 1:1212 WOOD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-1113
Practice Address - Country:US
Practice Address - Phone:215-568-2435
Practice Address - Fax:215-564-4740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA100910251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007513410003Medicaid