Provider Demographics
NPI:1023118114
Name:BETHANY NURSING HOME, INC.
Entity type:Organization
Organization Name:BETHANY NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:BAUM
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:330-492-7171
Mailing Address - Street 1:626 34TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-2943
Mailing Address - Country:US
Mailing Address - Phone:330-492-7171
Mailing Address - Fax:330-649-9440
Practice Address - Street 1:626 34TH ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-2943
Practice Address - Country:US
Practice Address - Phone:330-492-7171
Practice Address - Fax:330-649-9440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3302313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2437885Medicaid