Provider Demographics
NPI:1609380500
Name:BETHANY ON THE LAKE LLC
Entity Type:Organization
Organization Name:BETHANY ON THE LAKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-625-8741
Mailing Address - Street 1:638 SOUTHBEND AVE
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-2168
Mailing Address - Country:US
Mailing Address - Phone:507-697-5674
Mailing Address - Fax:
Practice Address - Street 1:1020 LARK ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2219
Practice Address - Country:US
Practice Address - Phone:320-762-1567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-30
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility