Healthcare Provider Details

I. General information

NPI: 1043451123
Provider Name (Legal Business Name): BETHANY ON 42ND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2009
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 UNIVERSITY DR S
FARGO ND
58103-1775
US

IV. Provider business mailing address

4255 30TH AVE S
FARGO ND
58104-8427
US

V. Phone/Fax

Practice location:
  • Phone: 701-239-3000
  • Fax: 701-239-3237
Mailing address:
  • Phone: 701-239-3000
  • Fax: 701-239-3237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1043451123
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer
# 2
Identifier30492
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: MR. SHAWN STUHAUG
Title or Position: PRESIDENT/CEO
Credential:
Phone: 701-239-3523