=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003385055
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETHSAIDA HEALTHCARE SYSTEM INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2018
-----------------------------------------------------
Last Update Date | 06/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2986 COUNTY ROAD 503
-----------------------------------------------------
City | WILDWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34785-8013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-753-2224
-----------------------------------------------------
Fax | 353-753-0833
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 910 OLD CAMP RD STE 144
-----------------------------------------------------
City | THE VILLAGES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32162-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-753-2224
-----------------------------------------------------
Fax | 353-753-0833
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FELIX C AGBO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 352-753-2224
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------