Provider Demographics
NPI:1669543716
Name:BEAVER DAM NURSING & REHAB CENTER, INC
Entity type:Organization
Organization Name:BEAVER DAM NURSING & REHAB CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-478-6181
Mailing Address - Street 1:1595 US HIGHWAY 231 S
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320-9463
Mailing Address - Country:US
Mailing Address - Phone:270-274-9646
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-12
Last Update Date:2015-08-18
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
KY7100125280Medicaid
KY12503595Medicaid
KY185334Medicare ID - Type Unspecified
KY7100125280Medicaid
KY5992340001Medicare NSC