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NPI Code Detail

MEDICARE: LB PHOENIX BETHANY HOME ROAD LLC

MEDICARE: LB PHOENIX BETHANY HOME ROAD LLC
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
1314000000XSkilled Nursing Facility035116AZ

General Provider Information

NPI Number : 1942355219
Entity Type Code : Organization
Provider Name (Legal Business Name) : LB PHOENIX BETHANY HOME ROAD LLC
Provider Business Mailing Address
First Line : 6246 N 19TH AVE
Second Line :
City : PHOENIX
State : AZ
Zip : 85015-1511
Country : US
Telephone Number : 602-433-6416
Fax Number : 602-433-6458
Provider Business Practice Location Address
First Line : 6246 N 19TH AVE
Second Line :
City : PHOENIX
State : AZ
Zip : 85015-1511
Country : US
Telephone Number : 602-433-6416
Fax Number : 602-433-6458
Authorized Official
Title or Position : GENERAL MANAGER
Name : MR. JAMES MICHAEL BAUSCH
Credential :
Telephone Number : 602-433-6416
Provider Enumeration Date : 01/24/2007
Last Update Date : 09/28/2007

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Directions to “LB PHOENIX BETHANY HOME ROAD LLC ” Practice Location

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