Provider Demographics
NPI:1356348809
Name:BETHESDA HOME
Entity type:Organization
Organization Name:BETHESDA HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-345-3331
Mailing Address - Street 1:129 W HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57274-1000
Mailing Address - Country:US
Mailing Address - Phone:605-345-3331
Mailing Address - Fax:605-345-3325
Practice Address - Street 1:129 W HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:SD
Practice Address - Zip Code:57274-1000
Practice Address - Country:US
Practice Address - Phone:605-345-3331
Practice Address - Fax:605-345-3325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10706314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD85071OtherWELLMARK BCBS
SD0150280Medicaid
SDS103160Medicare PIN
SD85071OtherWELLMARK BCBS