Healthcare Provider Details

I. General information

NPI: 1083602304
Provider Name (Legal Business Name): NEW BETHANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 BERKELEY DR
LOS BANOS CA
93635-9599
US

IV. Provider business mailing address

1441 BERKELEY DR
LOS BANOS CA
93635-9599
US

V. Phone/Fax

Practice location:
  • Phone: 209-827-8949
  • Fax: 209-827-6375
Mailing address:
  • Phone: 209-827-8949
  • Fax: 209-827-6375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number040000489
License Number StateCA

VIII. Authorized Official

Name: LUCINDA FONSECA
Title or Position: ADMINISTRATOR
Credential:
Phone: 209-827-8933