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General NPI Number Information
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NPI Number | 1528104643
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Entity Type | Organization
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Legal Business Name | BETHANY CHRISTIAN SERVICES INC.
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Dates
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Enumeration Date | 01/29/2007
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Last Update Date | 10/24/2013
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Provider Practice Location Address
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Address Line | 901 EASTERN AVE NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-1201
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Country | US
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Telephone | 616-224-7617
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Fax | 616-224-7593
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Provider Business Mailing Address
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Address Line | 901 EASTERN AVE NE P.O. BOX 294
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-1201
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Country | US
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Telephone | 616-224-7617
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Fax | 616-224-7593
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Authorized Official
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Title or Position | BRANCH DIRECTOR
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Name | GEORGE JOHN TYNDALL
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Credential | MSW
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Telephone | 616-224-7617
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 635720364
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | CB410200976
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 410218
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License Number State | MI
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