=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003439472
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETHEL SKILLED HOME CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2020
-----------------------------------------------------
Last Update Date | 12/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3611 BOULEVARD
-----------------------------------------------------
City | COLONIAL HEIGHTS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23834-1344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-523-5479
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6024 IRONSTONE DR
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23234-7725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-523-5479
-----------------------------------------------------
Fax | 804-374-8889
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/OWNER
-----------------------------------------------------
Name | DR. JESSY NWUBA
-----------------------------------------------------
Credential | REGISTERED NURSE
-----------------------------------------------------
Telephone | 571-523-5479
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------