Provider Demographics
NPI:1154316438
Name:BETHANY LUTHERAN HOMES, INC.
Entity Type:Organization
Organization Name:BETHANY LUTHERAN HOMES, INC.
Other - Org Name:BETHANY RIVERSIDE
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:A
Authorized Official - Last Name:GARVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-406-3888
Mailing Address - Street 1:2575 7TH ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5249
Mailing Address - Country:US
Mailing Address - Phone:608-775-8200
Mailing Address - Fax:608-775-8270
Practice Address - Street 1:2575 7TH ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5249
Practice Address - Country:US
Practice Address - Phone:608-775-8200
Practice Address - Fax:608-775-8270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2707314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20128200Medicaid
WI525455Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER