Organization
BETHPHAGE MISSION WEST
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DEAN WILSON (VP ACCOUNTING)
(402) 896-3884
Entity
Organization
Contact information
Practice address
920 LOBO CANYON RD, SUITE 5A, GRANTS, NM 87020-2173
(505) 287-9333
(505) 287-9336
Mailing address
4980 S 118TH ST, OMAHA, NE 68137-2220
(402) 896-3884
(402) 894-4780
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
D0103
—
NM
Enumeration date
05/04/2007
Last updated
08/22/2020
Update your record
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