Provider Demographics
NPI:1124081229
Name:BETHEL HOME, INC.
Entity type:Organization
Organization Name:BETHEL HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:KERN
Authorized Official - Suffix:
Authorized Official - Credentials:BBA, MBA, CPA
Authorized Official - Phone:920-232-5220
Mailing Address - Street 1:225 N EAGLE ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-4125
Mailing Address - Country:US
Mailing Address - Phone:920-235-4653
Mailing Address - Fax:920-235-2771
Practice Address - Street 1:225 N EAGLE ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-4125
Practice Address - Country:US
Practice Address - Phone:920-235-4653
Practice Address - Fax:920-235-2771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2005314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20127400Medicaid
WI20127400Medicaid