Provider Demographics
NPI:1497736615
Name:BETHEL LUTHERAN HOME
Entity Type:Organization
Organization Name:BETHEL LUTHERAN HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:IVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-256-4936
Mailing Address - Street 1:1001 S EGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:SD
Mailing Address - Zip Code:57042-3336
Mailing Address - Country:US
Mailing Address - Phone:605-256-4539
Mailing Address - Fax:605-256-4007
Practice Address - Street 1:1001 S EGAN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:SD
Practice Address - Zip Code:57042-3336
Practice Address - Country:US
Practice Address - Phone:605-256-4539
Practice Address - Fax:605-256-4007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10644314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0150390Medicaid
SD43-5076Medicare ID - Type UnspecifiedMEDICARE NUMBER