Provider Demographics
NPI:1003807280
Name:BETHANY LUTHERAN HOME
Entity type:Organization
Organization Name:BETHANY LUTHERAN HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN SICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-328-9500
Mailing Address - Street 1:7 ELLIOTT ST
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-0239
Mailing Address - Country:US
Mailing Address - Phone:712-328-9500
Mailing Address - Fax:712-309-0190
Practice Address - Street 1:7 ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-0239
Practice Address - Country:US
Practice Address - Phone:712-328-9500
Practice Address - Fax:712-309-0190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0800227Medicaid
IA165524Medicare ID - Type Unspecified