Provider Demographics
NPI:1649482639
Name:BETHPHAGE MISSION WEST
Entity type:Organization
Organization Name:BETHPHAGE MISSION WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-896-3884
Mailing Address - Street 1:4980 S 118TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-2220
Mailing Address - Country:US
Mailing Address - Phone:402-896-3884
Mailing Address - Fax:402-894-4780
Practice Address - Street 1:920 LOBO CANYON RD
Practice Address - Street 2:SUITE 5A
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2173
Practice Address - Country:US
Practice Address - Phone:505-287-9333
Practice Address - Fax:505-287-9336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMD0103Medicaid