Healthcare Provider Details

I. General information

NPI: 1962779389
Provider Name (Legal Business Name): BETHLEHEM HOUSE RESIDENCE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2011
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 E 30TH ST
INDIANAPOLIS IN
46205-3904
US

IV. Provider business mailing address

130 E 30TH ST
INDIANAPOLIS IN
46205-3904
US

V. Phone/Fax

Practice location:
  • Phone: 317-920-1519
  • Fax: 317-920-1515
Mailing address:
  • Phone: 317-920-1519
  • Fax: 317-920-1515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. NATHAN L RUSH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 317-920-1519