Healthcare Provider Details

I. General information

NPI: 1679124705
Provider Name (Legal Business Name): BEDROCK HCS AT BEAVER DAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 ROEDL CT
BEAVER DAM WI
53916-2934
US

IV. Provider business mailing address

WORKSPACES AT BITBEAN C/O ESTHER TILLIM 1776 AVE OF THE STATES SUITE 302
LAKEWOOD NJ
08701
US

V. Phone/Fax

Practice location:
  • Phone: 920-887-7191
  • Fax:
Mailing address:
  • Phone: 732-328-7499
  • 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: BOOKKEEPER
Credential:
Phone: 732-328-7499