Provider Demographics
NPI:1699414375
Name:BEDROCK HCS AT BECKER DR WI OPCO LLC
Entity Type:Organization
Organization Name:BEDROCK HCS AT BECKER DR WI OPCO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-750-6987
Mailing Address - Street 1:150 OBERLIN AVE N STE 6
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4535
Mailing Address - Country:US
Mailing Address - Phone:732-800-6005
Mailing Address - Fax:
Practice Address - Street 1:1700 C A BECKER DR
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4714
Practice Address - Country:US
Practice Address - Phone:262-637-9751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility