Provider Demographics
NPI:1740418920
Name:BETHANY TOWERS BASIC CARE
Entity Type:Organization
Organization Name:BETHANY TOWERS BASIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:STUHAUG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-239-3523
Mailing Address - Street 1:201 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1775
Mailing Address - Country:US
Mailing Address - Phone:701-239-3000
Mailing Address - Fax:701-239-3237
Practice Address - Street 1:201 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1775
Practice Address - Country:US
Practice Address - Phone:701-239-3000
Practice Address - Fax:701-239-3237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND30781Medicaid