Provider Demographics
NPI:1265090559
Name:BEAVER DAM ASSISTED LIVING, LLC
Entity type:Organization
Organization Name:BEAVER DAM ASSISTED LIVING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MISS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BITTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-378-1913
Mailing Address - Street 1:5555 W GRANDE MARKET DR STE A
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8170
Mailing Address - Country:US
Mailing Address - Phone:920-574-3833
Mailing Address - Fax:920-574-3850
Practice Address - Street 1:104 FAKES CT
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2699
Practice Address - Country:US
Practice Address - Phone:920-356-9818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-31
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)