MEDICARE: BETHEL DESTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1669318861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETHEL DESTA

Provider Business Mailing Address
First Line	:	6431 FANNIN ST STE JJL 308S
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-1501
Country	:	US
Telephone Number	:	713-500-7617
Fax Number	:	713-500-7606

Provider Business Practice Location Address
First Line	:	6431 FANNIN ST STE JJL 308S
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-1501
Country	:	US
Telephone Number	:	713-500-7617
Fax Number	:	713-500-7606

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2026
Last Update Date	:	04/28/2026

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Directions to “ BETHEL DESTA ” Practice Location

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