Provider Demographics
NPI:1427050525
Name:BETHESDA
Entity type:Organization
Organization Name:BETHESDA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALANA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:ZIEHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-235-9532
Mailing Address - Street 1:1012 3RD ST SE
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-4554
Mailing Address - Country:US
Mailing Address - Phone:320-235-3924
Mailing Address - Fax:320-231-3399
Practice Address - Street 1:1012 3RD ST SE
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-4554
Practice Address - Country:US
Practice Address - Phone:320-235-3924
Practice Address - Fax:320-231-3399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-02
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN327806314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN803742600Medicaid
MN8658BEOtherBLUE PLUS & BCBS
MN803742600Medicaid