Basic Information
| Provider Information | |||||||||
| NPI: | 1538321781 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEAVER DAM HEALTH CARE MANOR INC | ||||||||
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| OtherOrganizationName: | BEAVER DAM HEALTH CARE MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 COURTLAND ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328041340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079753000 | ||||||||
| FaxNumber: | 4079753090 | ||||||||
| Practice Location | |||||||||
| Address1: | 1595 US HIGHWAY 231 S | ||||||||
| Address2: | |||||||||
| City: | BEAVER DAM | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423209463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702749646 | ||||||||
| FaxNumber: | 2702749646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | RODMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASST SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4079753011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 100353 | KY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.