Provider Demographics
NPI:1538321781
Name:BEAVER DAM HEALTH CARE MANOR INC
Entity Type:Organization
Organization Name:BEAVER DAM HEALTH CARE MANOR INC
Other - Org Name:BEAVER DAM HEALTH CARE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-975-3011
Mailing Address - Street 1:602 COURTLAND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-1340
Mailing Address - Country:US
Mailing Address - Phone:407-975-3000
Mailing Address - Fax:407-975-3090
Practice Address - Street 1:1595 US HIGHWAY 231 S
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320-9463
Practice Address - Country:US
Practice Address - Phone:270-274-9646
Practice Address - Fax:270-274-9646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100353314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
3936970001Medicare NSC