=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679124705
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEDROCK HCS AT BEAVER DAM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2019
-----------------------------------------------------
Last Update Date | 09/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 ROEDL CT
-----------------------------------------------------
City | BEAVER DAM
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53916-2934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-887-7191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | WORKSPACES AT BITBEAN C/O ESTHER TILLIM 1776 AVE OF THE STATES SUITE 302
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-328-7499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOOKKEEPER
-----------------------------------------------------
Name | ESTHER TILLIM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-328-7499
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------