MEDICARE: CASSANDRA FAYE BETHEA

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1104019520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASSANDRA FAYE BETHEA

Provider Business Mailing Address
First Line	:	2007 STEPPING STONE LN
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28110-7106
Country	:	US
Telephone Number	:	704-577-0474
Fax Number	:

Provider Business Practice Location Address
First Line	:	2007 STEPPING STONE LN
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28110-7106
Country	:	US
Telephone Number	:	704-577-0474
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2007
Last Update Date	:	08/20/2007

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