Healthcare Provider Details

I. General information

NPI: 1275813453
Provider Name (Legal Business Name): BETHANY CHRISTIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 36TH ST SE
GRAND RAPIDS MI
49508
US

IV. Provider business mailing address

901 EASTERN AVENUE NE
GRAND RAPIDS MI
49501-0294
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8093
  • Fax:
Mailing address:
  • Phone: 616-965-8093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number4101006467
License Number StateMI

VIII. Authorized Official

Name: MR. GEORGE TYNDALL
Title or Position: DIRECTOR
Credential: LMSW
Phone: 616-284-7543