MEDICARE: BLUE CARE OPCO FORT DODGE - NORTH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility

General Provider Information

NPI Number	:	1194460311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE CARE OPCO FORT DODGE - NORTH, LLC

Provider Business Mailing Address
First Line	:	36 AIRPORT RD # S206
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-7034
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2721 10TH AVE N
Second Line	:
City	:	FORT DODGE
State	:	IA
Zip	:	50501-2834
Country	:	US
Telephone Number	:	732-637-9191
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHMEUL HAIKINS
Credential	:
Telephone Number	:	732-637-9191

Provider Enumeration Date	:	05/02/2022
Last Update Date	:	05/02/2022

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