Provider Demographics
NPI:1306624283
Name:BETHANY CHRISTIAN SERVCIES OF CA
Entity type:Organization
Organization Name:BETHANY CHRISTIAN SERVCIES OF CA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:STOUTMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-224-7429
Mailing Address - Street 1:3048 HAHN DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6503
Mailing Address - Country:US
Mailing Address - Phone:209-522-5121
Mailing Address - Fax:209-522-4045
Practice Address - Street 1:3048 HAHN DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6503
Practice Address - Country:US
Practice Address - Phone:209-522-5121
Practice Address - Fax:209-522-4045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty