Basic Information
| Provider Information | |||||||||
| NPI: | 1619487741 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEREA HEALTHCARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BEREA ACQUISITION, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 PROVIDER CT | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404758488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596230898 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 601 RICHMOND RD N | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404038788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596230898 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2017 | ||||||||
| LastUpdateDate: | 10/03/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PHILIPSON | ||||||||
| AuthorizedOfficialFirstName: | BENT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8596230898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.