Provider Demographics
NPI:1548415342
Name:BETHESDA LUTHERAN HOMES & SERVICES INC
Entity Type:Organization
Organization Name:BETHESDA LUTHERAN HOMES & SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLAO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KACZMARSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-206-4406
Mailing Address - Street 1:600 HOFFMANN DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-6223
Mailing Address - Country:US
Mailing Address - Phone:920-261-3050
Mailing Address - Fax:
Practice Address - Street 1:14907 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-3151
Practice Address - Country:US
Practice Address - Phone:815-436-1901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========003Medicaid