Provider Demographics
NPI:1144769654
Name:BETHANY HOME HEALTH, INC
Entity Type:Organization
Organization Name:BETHANY HOME HEALTH, INC
Other - Org Name:BETHANY HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
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:56542-0028
Mailing Address - Country:US
Mailing Address - Phone:218-280-1609
Mailing Address - Fax:218-435-1143
Practice Address - Street 1:903 HILLIGOSS BLVD SE
Practice Address - Street 2:
Practice Address - City:FOSSTON
Practice Address - State:MN
Practice Address - Zip Code:56542-1541
Practice Address - Country:US
Practice Address - Phone:218-280-1609
Practice Address - Fax:218-435-1143
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BETHANY BOARD AND LODGE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN379186251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA496997400Medicaid
MNA926615400Medicaid