=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851379465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETHAMY LIVING CENTER LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2006
-----------------------------------------------------
Last Update Date | 07/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2055 PALMETTO ST
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-461-6613
-----------------------------------------------------
Fax | 727-442-2835
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2055 PALMETTO ST
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-461-6613
-----------------------------------------------------
Fax | 727-442-2835
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. BRIAN REYNOLDS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-513-8738
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | SNF1083095
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------