Healthcare Provider Details

I. General information

NPI: 1457652646
Provider Name (Legal Business Name): BETHANY HH OF LAKE JACKSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 THAT WAY ST SUITE C
LAKE JACKSON TX
77566-5211
US

IV. Provider business mailing address

PO BOX 260875
PLANO TX
75026-0875
US

V. Phone/Fax

Practice location:
  • Phone: 979-297-1414
  • Fax: 979-297-1818
Mailing address:
  • Phone: 972-248-2441
  • Fax: 972-248-0773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: BRADLEY P LASSITER
Title or Position: CEO
Credential:
Phone: 972-248-2441