Provider Demographics
NPI:1780168054
Name:BETHS PLACE LLC
Entity type:Organization
Organization Name:BETHS PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LADC/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CASSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KASOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:701-396-1190
Mailing Address - Street 1:1606 30TH AVE S STE 2
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5147
Mailing Address - Country:US
Mailing Address - Phone:701-936-1190
Mailing Address - Fax:
Practice Address - Street 1:1606 30TH AVE S STE 2
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5147
Practice Address - Country:US
Practice Address - Phone:701-936-1190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-21
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center