Provider Demographics
NPI:1033429683
Name:BETHESDA LUTHERAN COMMUNITIES
Entity Type:Organization
Organization Name:BETHESDA LUTHERAN COMMUNITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ACCOUNTS RECEIVABLE
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-206-4486
Mailing Address - Street 1:600 HOFFMANN DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-6223
Mailing Address - Country:US
Mailing Address - Phone:920-261-3050
Mailing Address - Fax:
Practice Address - Street 1:600 HOFFMANN DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-6223
Practice Address - Country:US
Practice Address - Phone:920-261-3050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI99533340Medicaid