Provider Demographics
NPI:1215934963
Name:BETHANY HOME INC
Entity type:Organization
Organization Name:BETHANY HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:S
Authorized Official - Last Name:REICHENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-942-1400
Mailing Address - Street 1:1226 BERLIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-1991
Mailing Address - Country:US
Mailing Address - Phone:715-258-5521
Mailing Address - Fax:715-258-7051
Practice Address - Street 1:1226 BERLIN ST
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1991
Practice Address - Country:US
Practice Address - Phone:715-258-5521
Practice Address - Fax:715-258-7051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1874310400000X
WI963314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21054200Medicaid
WI525538Medicare ID - Type Unspecified