MEDICARE: BETHESDA LUTHERAN COMMUNITIES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720359961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BETHESDA LUTHERAN COMMUNITIES INC

Provider Business Mailing Address
First Line	:	600 HOFFMANN DR
Second Line	:
City	:	WATERTOWN
State	:	WI
Zip	:	53094-6223
Country	:	US
Telephone Number	:	920-206-4458
Fax Number	:

Provider Business Practice Location Address
First Line	:	5122 AMBERGLOW DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-3204
Country	:	US
Telephone Number	:	920-206-4458
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF ACCOUNTING SERVICES
Name	:	MRS. KAREN HOLTON
Credential	:
Telephone Number	:	920-206-4458

Provider Enumeration Date	:	01/19/2012
Last Update Date	:	01/19/2012

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