Provider Demographics
NPI:1073618997
Name:BETHANY COVENANT HOME
Entity Type:Organization
Organization Name:BETHANY COVENANT HOME
Other - Org Name:BETHANY COVENANT VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:K
Authorized Official - Last Name:FISK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-878-2295
Mailing Address - Street 1:2309 HAYES ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-3934
Mailing Address - Country:US
Mailing Address - Phone:612-781-2691
Mailing Address - Fax:612-781-8835
Practice Address - Street 1:2309 HAYES ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-3934
Practice Address - Country:US
Practice Address - Phone:612-781-2691
Practice Address - Fax:612-781-8835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNNO NUMBERS USED314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN245578Medicare ID - Type Unspecified