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General NPI Number Information
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NPI Number | 1104118108
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Entity Type | Organization
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Legal Business Name | BETH'EL PERSONAL CARE HOME
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Dates
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Enumeration Date | 05/09/2011
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Last Update Date | 05/09/2011
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Provider Practice Location Address
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Address Line | 4327 WEBB MEADOWS DR
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City | LOGANVILLE
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State | GA
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Zip | 30052-7579
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Country | US
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Telephone | 770-736-6439
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Fax | 678-609-5540
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Provider Business Mailing Address
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Address Line | 4327 WEBB MEADOWS DR
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City | LOGANVILLE
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State | GA
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Zip | 30052-7579
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Country | US
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Telephone | 770-736-6439
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Fax | 678-609-5540
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Authorized Official
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Title or Position | DIRECTOR
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Name | MS. ABOSEDE ADETUTU OSHINUBI
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Credential | RD, LD
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Telephone | 770-736-6439
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0630X
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Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
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License Number | 756428113A
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License Number State | GA
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