Basic Information
Provider Information | |||||||||
NPI: | 1669543716 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEAVER DAM NURSING & REHAB CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1595 US HIGHWAY 231 S | ||||||||
Address2: |   | ||||||||
City: | BEAVER DAM | ||||||||
State: | KY | ||||||||
PostalCode: | 423209463 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2702749646 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1595 US HIGHWAY 231 S | ||||||||
Address2: |   | ||||||||
City: | BEAVER DAM | ||||||||
State: | KY | ||||||||
PostalCode: | 423209463 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2702749646 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/12/2006 | ||||||||
LastUpdateDate: | 08/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COX | ||||||||
AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6154786181 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 100353 | KY | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 7100125280 | 05 | KY |   | MEDICAID | 12503595 | 05 | KY |   | MEDICAID |