MEDICARE: BETHANY HH OF CLEAR LAKE, LLC

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	251E00000X	Home Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275765695
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BETHANY HH OF CLEAR LAKE, LLC

Provider Business Mailing Address
First Line	:	5000 LEGACY DR
Second Line	:	SUITE 360
City	:	PLANO
State	:	TX
Zip	:	75024-3100
Country	:	US
Telephone Number	:	972-248-2441
Fax Number	:	972-248-0773

Provider Business Practice Location Address
First Line	:	1100 NASA PKWY
Second Line	:	SUITE 100
City	:	HOUSTON
State	:	TX
Zip	:	77058-3325
Country	:	US
Telephone Number	:	218-984-7670
Fax Number	:	832-224-4315

Authorized Official
Title or Position	:	OWNER
Name	:	BRADLEY P. LASSITER
Credential	:
Telephone Number	:	972-248-2441

Provider Enumeration Date	:	08/18/2009
Last Update Date	:	09/29/2016

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