Provider Demographics
NPI:1467447540
Name:BETHEL CENTER, LLC
Entity Type:Organization
Organization Name:BETHEL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLASS
Authorized Official - Middle Name:B
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-647-9004
Mailing Address - Street 1:121 S WATER AVE
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-2902
Mailing Address - Country:US
Mailing Address - Phone:615-989-7881
Mailing Address - Fax:
Practice Address - Street 1:8014 BETHEL RD
Practice Address - Street 2:
Practice Address - City:ARPIN
Practice Address - State:WI
Practice Address - Zip Code:54410-9558
Practice Address - Country:US
Practice Address - Phone:715-652-2103
Practice Address - Fax:859-281-5150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2018-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3079314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20191600Medicaid
WI525360Medicare ID - Type Unspecified
WI20191600Medicaid