Provider Demographics
NPI:1750357950
Name:BETHESDA LONG TERM CARE, INC.
Entity type:Organization
Organization Name:BETHESDA LONG TERM CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:5943 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-4715
Practice Address - Country:US
Practice Address - Phone:314-846-2000
Practice Address - Fax:314-846-4661
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
MO032167314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101496206Medicaid
MO101496206Medicaid