Healthcare Provider Details

I. General information

NPI: 1124656202
Provider Name (Legal Business Name): BEDROCK HCS AT DAYTONA FL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 N WILLIAMSON BLVD
DAYTONA BEACH FL
32114-7185
US

IV. Provider business mailing address

792 VINE AVE BSMT
LAKEWOOD NJ
08701-5340
US

V. Phone/Fax

Practice location:
  • Phone: 732-328-7499
  • Fax:
Mailing address:
  • Phone: 347-598-1029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: ESTHER TILLIM
Title or Position: CONTROLLER
Credential:
Phone: 732-328-7499