Healthcare Provider Details

I. General information

NPI: 1265090559
Provider Name (Legal Business Name): BEAVER DAM ASSISTED LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 07/03/2020
Certification Date: 07/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 FAKES CT
BEAVER DAM WI
53916-2699
US

IV. Provider business mailing address

5555 W GRANDE MARKET DR STE A
APPLETON WI
54913-8170
US

V. Phone/Fax

Practice location:
  • Phone: 920-356-9818
  • Fax:
Mailing address:
  • Phone: 920-574-3833
  • Fax: 920-574-3850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: MISS BARBARA ANN BITTNER
Title or Position: COO
Credential:
Phone: 920-378-1913