Provider Demographics
NPI:1023063856
Name:BETHANY LUTHERAN HOME
Entity type:Organization
Organization Name:BETHANY LUTHERAN HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:FRED
Authorized Official - Last Name:SEVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-338-2351
Mailing Address - Street 1:1901 S HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-2407
Mailing Address - Country:US
Mailing Address - Phone:605-338-2351
Mailing Address - Fax:605-338-0241
Practice Address - Street 1:1901 S HOLLY AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-2407
Practice Address - Country:US
Practice Address - Phone:605-338-2351
Practice Address - Fax:605-338-0241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10677314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0150010Medicaid
85096OtherBC & BS
SD0150010Medicaid