MEDICARE: THE BETHEL GROUP HOME INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility	2169	OH

General Provider Information

NPI Number	:	1013349513
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BETHEL GROUP HOME INC.

Provider Business Mailing Address
First Line	:	2107 4TH ST
Second Line	:
City	:	CUYAHOGA FALLS
State	:	OH
Zip	:	44221-3211
Country	:	US
Telephone Number	:	330-928-5757
Fax Number	:

Provider Business Practice Location Address
First Line	:	2107 4TH ST
Second Line	:
City	:	CUYAHOGA FALLS
State	:	OH
Zip	:	44221-3211
Country	:	US
Telephone Number	:	330-928-5757
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DEONNA LACRISSA SAMUEL
Credential	:	M.S.
Telephone Number	:	330-928-5757

Provider Enumeration Date	:	08/07/2013
Last Update Date	:	08/07/2013

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