Provider Demographics
NPI:1720359961
Name:BETHESDA LUTHERAN COMMUNITIES INC
Entity Type:Organization
Organization Name:BETHESDA LUTHERAN COMMUNITIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ACCOUNTING SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-206-4458
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:920-206-4458
Mailing Address - Fax:
Practice Address - Street 1:5122 AMBERGLOW DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-3204
Practice Address - Country:US
Practice Address - Phone:920-206-4458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI99533340Medicaid