Healthcare Provider Details

I. General information

NPI: 1356348809
Provider Name (Legal Business Name): BETHESDA HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 W HIGHWAY 12
WEBSTER SD
57274-1000
US

IV. Provider business mailing address

129 W HIGHWAY 12
WEBSTER SD
57274-1000
US

V. Phone/Fax

Practice location:
  • Phone: 605-345-3331
  • Fax: 605-345-3325
Mailing address:
  • Phone: 605-345-3331
  • Fax: 605-345-3325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number10706
License Number StateSD

VII. Legacy identifiers

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

# 1
Identifier85071
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerWELLMARK BCBS
# 2
Identifier0150280
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name: DAVID A ROGERS
Title or Position: ADMINISTRATOR
Credential:
Phone: 605-345-3331