Basic Information
| Provider Information | |||||||||
| NPI: | 1124081229 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BETHEL HOME, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 N EAGLE ST | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549024125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202354653 | ||||||||
| FaxNumber: | 9202352771 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 N EAGLE ST | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549024125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202354653 | ||||||||
| FaxNumber: | 9202352771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 07/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | KERN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 9202325220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | BBA, MBA, CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2005 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20127400 | 05 | WI | MEDICAID |