Provider Demographics
NPI:1053405803
Name:BETHANY HOME
Entity type:Organization
Organization Name:BETHANY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GLINDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MANTERNACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-556-5233
Mailing Address - Street 1:1005 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-3499
Mailing Address - Country:US
Mailing Address - Phone:563-556-5233
Mailing Address - Fax:563-556-3078
Practice Address - Street 1:1005 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-3499
Practice Address - Country:US
Practice Address - Phone:563-556-5233
Practice Address - Fax:563-556-3078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAN-307313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0800219Medicaid
IA0800219Medicaid