Provider Demographics
NPI:1952399503
Name:BETHANY HOME, INC
Entity Type:Organization
Organization Name:BETHANY HOME, INC
Other - Org Name:BETHANY HOME NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:DASHER
Authorized Official - Last Name:LIVINGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-764-7960
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:MILLEN
Mailing Address - State:GA
Mailing Address - Zip Code:30442-0600
Mailing Address - Country:US
Mailing Address - Phone:478-982-2531
Mailing Address - Fax:478-982-3131
Practice Address - Street 1:466 S GRAY ST
Practice Address - Street 2:
Practice Address - City:MILLEN
Practice Address - State:GA
Practice Address - Zip Code:30442-5237
Practice Address - Country:US
Practice Address - Phone:478-982-2531
Practice Address - Fax:478-982-3131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-082-014314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00140269AMedicaid
GA00140269AMedicaid
GA11-5700Medicare Oscar/Certification