=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023118114
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETHANY NURSING HOME, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2006
-----------------------------------------------------
Last Update Date | 07/25/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 626 34TH ST NW
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44709-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-492-7171
-----------------------------------------------------
Fax | 330-649-9440
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 626 34TH ST NW
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44709-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-492-7171
-----------------------------------------------------
Fax | 330-649-9440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. JOHN F. BAUM
-----------------------------------------------------
Credential | N.H.A.
-----------------------------------------------------
Telephone | 330-492-7171
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 3302
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------