Provider Demographics
NPI:1629296306
Name:ROLLINS BEDFORD CORPORATION
Entity Type:Organization
Organization Name:ROLLINS BEDFORD CORPORATION
Other - Org Name:RUSSELLVILLE HEALTH CARE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEHTJE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-975-3010
Mailing Address - Street 1:602 COURTLAND ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-1360
Mailing Address - Country:US
Mailing Address - Phone:407-975-3000
Mailing Address - Fax:407-975-3090
Practice Address - Street 1:683 E 3RD ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-1872
Practice Address - Country:US
Practice Address - Phone:270-726-9049
Practice Address - Fax:270-726-8706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100299313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12503736Medicaid
KY90003948Medicaid
KY12503736Medicaid
KY185313Medicare Oscar/Certification