1073618997 NPI number — BETHANY COVENANT HOME

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073618997 NPI number — BETHANY COVENANT HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BETHANY COVENANT HOME
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BETHANY COVENANT VILLAGE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073618997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2309 HAYES ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55418-3934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-781-2691
Provider Business Mailing Address Fax Number:
612-781-8835

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2309 HAYES ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55418-3934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-781-2691
Provider Business Practice Location Address Fax Number:
612-781-8835
Provider Enumeration Date:
09/14/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FISK
Authorized Official First Name:
RICK
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-878-2295

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NO NUMBERS USED , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)