Provider Demographics
NPI:1043451123
Name:BETHANY ON 42ND
Entity Type:Organization
Organization Name:BETHANY ON 42ND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:STUHAUG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-239-3523
Mailing Address - Street 1:4255 30TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8427
Mailing Address - Country:US
Mailing Address - Phone:701-239-3000
Mailing Address - Fax:701-239-3237
Practice Address - Street 1:201 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1775
Practice Address - Country:US
Practice Address - Phone:701-239-3000
Practice Address - Fax:701-239-3237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1043451123Medicaid
ND30492Medicaid
MN1043451123Medicaid