Provider Demographics
NPI:1679124705
Name:BEDROCK HCS AT BEAVER DAM LLC
Entity Type:Organization
Organization Name:BEDROCK HCS AT BEAVER DAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-328-7499
Mailing Address - Street 1:WORKSPACES AT BITBEAN C/O ESTHER TILLIM
Mailing Address - Street 2:1776 AVE OF THE STATES SUITE 302
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701
Mailing Address - Country:US
Mailing Address - Phone:732-328-7499
Mailing Address - Fax:
Practice Address - Street 1:410 ROEDL CT
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2934
Practice Address - Country:US
Practice Address - Phone:920-887-7191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility