MEDICARE: BAWITDABA 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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1437852027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAWITDABA LLC

Provider Business Mailing Address
First Line	:	2266 LAVA RIDGE CT
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-2856
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	455 FLORIN RD
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95831-2024
Country	:	US
Telephone Number	:	916-393-2550
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	DAN BUSHNELL
Credential	:
Telephone Number	:	949-508-8370

Provider Enumeration Date	:	03/23/2023
Last Update Date	:	03/23/2023

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