Provider Demographics
NPI:1386631240
Name:BETHEL HOME AND SERVICES, INC.
Entity type:Organization
Organization Name:BETHEL HOME AND SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS TEAM LAND
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:STOUT TEWALT
Authorized Official - Suffix:
Authorized Official - Credentials:CSW
Authorized Official - Phone:608-637-2171
Mailing Address - Street 1:614 SOUTH ROCK AVENUE
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-1936
Mailing Address - Country:US
Mailing Address - Phone:608-637-6355
Mailing Address - Fax:608-637-8303
Practice Address - Street 1:614 SOUTH ROCK AVENUE
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-1936
Practice Address - Country:US
Practice Address - Phone:608-637-2171
Practice Address - Fax:608-637-8303
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BETHEL HOME AND SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-05
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20151800Medicaid
WI100012558Medicaid
WI525591Medicare ID - Type Unspecified