Provider Demographics
NPI:1114497773
Name:BETHANY BOARD AND LODGE, INC
Entity Type:Organization
Organization Name:BETHANY BOARD AND LODGE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-280-1609
Mailing Address - Street 1:PO BOX 28
Mailing Address - Street 2:
Mailing Address - City:FOSSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56542
Mailing Address - Country:US
Mailing Address - Phone:218-435-1044
Mailing Address - Fax:218-435-1143
Practice Address - Street 1:203 S INDERLEE AVE
Practice Address - Street 2:
Practice Address - City:FOSSTON
Practice Address - State:MN
Practice Address - Zip Code:56542
Practice Address - Country:US
Practice Address - Phone:218-435-1044
Practice Address - Fax:218-435-1143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility