Healthcare Provider Details

I. General information

NPI: 1477581544
Provider Name (Legal Business Name): BETHANY MEDICAL SUPPLY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N AZUSA AVE STE 111
LA PUENTE CA
91744-4261
US

IV. Provider business mailing address

525 N AZUSA AVE STE 111
LA PUENTE CA
91744-4261
US

V. Phone/Fax

Practice location:
  • Phone: 626-961-8699
  • Fax: 626-961-8806
Mailing address:
  • Phone: 626-961-8699
  • Fax: 626-961-8806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number332B00000X
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number103509
License Number StateCA

VIII. Authorized Official

Name: MRS. HIBEST ESSAYAS
Title or Position: CEO PRESIDENT
Credential:
Phone: 626-961-8699