Healthcare Provider Details

I. General information

NPI: 1538321781
Provider Name (Legal Business Name): BEAVER DAM HEALTH CARE MANOR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1595 US HIGHWAY 231 S
BEAVER DAM KY
42320-9463
US

IV. Provider business mailing address

602 COURTLAND ST STE 200
ORLANDO FL
32804-1340
US

V. Phone/Fax

Practice location:
  • Phone: 270-274-9646
  • Fax: 270-274-9646
Mailing address:
  • Phone: 407-975-3000
  • Fax: 407-975-3090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100353
License Number StateKY

VIII. Authorized Official

Name: MR. DAVID RODMAN
Title or Position: ASST SECRETARY
Credential:
Phone: 407-975-3011