Basic Information
| Provider Information | |||||||||
| NPI: | 1427276104 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROLLINS BEDFORD CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRINCETON HEALTH CARE MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 COURTLAND ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328041360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079753000 | ||||||||
| FaxNumber: | 4079753090 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424456211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703653541 | ||||||||
| FaxNumber: | 2703655064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WEHTJE | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP CFO | ||||||||
| AuthorizedOfficialTelephone: | 4079753010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 100049 | KY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 12504106 | 05 | KY | MEDICAID | 90003955 | 05 | KY | MEDICAID |