Basic Information
| Provider Information | |||||||||
| NPI: | 1265090559 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEAVER DAM ASSISTED LIVING, LLC | ||||||||
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| OtherOrganizationName: | BEAVER DAM ASSISTED LIVING AND MEMORY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5555 W GRANDE MARKET DR STE A | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549138170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9205743833 | ||||||||
| FaxNumber: | 9205743850 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 FAKES CT | ||||||||
| Address2: | |||||||||
| City: | BEAVER DAM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539162699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203569818 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2019 | ||||||||
| LastUpdateDate: | 07/03/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BITTNER | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9203781913 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| NPICertificationDate: | 07/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.