=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952308942
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEAUMONT RETIREMENT SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 N ITHAN AVE
-----------------------------------------------------
City | BRYN MAWR
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19010-1782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-526-7000
-----------------------------------------------------
Fax | 610-525-0293
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 N ITHAN AVE
-----------------------------------------------------
City | BRYN MAWR
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19010-1782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-526-7000
-----------------------------------------------------
Fax | 610-525-0293
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | MR. J. DAVID MUSTIN
-----------------------------------------------------
Credential | NHA, MBA, CPA
-----------------------------------------------------
Telephone | 610-526-7000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 026802
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------