Healthcare Provider Details

I. General information

NPI: 1164353405
Provider Name (Legal Business Name): BETHANY MISSIONARY BAPTIST CHURCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 TY TY SYCAMORE RD
TY TY GA
31795-3314
US

IV. Provider business mailing address

146 TY TY SYCAMORE RD
TY TY GA
31795-3314
US

V. Phone/Fax

Practice location:
  • Phone: 678-986-1436
  • Fax:
Mailing address:
  • Phone: 678-986-1436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL LEE PRIDGON
Title or Position: PASTOR/CEO
Credential:
Phone: 678-986-1436