MEDICARE: BETHESDA HEALTHCARE AGENCY, 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	251E00000X	Home Health Agency	010613	TX

General Provider Information

NPI Number	:	1578516878
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BETHESDA HEALTHCARE AGENCY, INC

Provider Business Mailing Address
First Line	:	5232 MIRROR LAKE DR
Second Line	:
City	:	HALTOM CITY
State	:	TX
Zip	:	76117-1325
Country	:	US
Telephone Number	:	817-849-8502
Fax Number	:	817-788-5774

Provider Business Practice Location Address
First Line	:	5232 MIRROR LAKE DR
Second Line	:
City	:	HALTOM CITY
State	:	TX
Zip	:	76117-1325
Country	:	US
Telephone Number	:	817-849-8502
Fax Number	:	817-788-5774

Authorized Official
Title or Position	:	CEO
Name	:	MR. KENNETH MITCHEL NASIBOYE
Credential	:	R.N.
Telephone Number	:	817-849-8502

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	07/13/2010

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