Basic Information
| Provider Information | |||||||||
| NPI: | 1679791347 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROLLINS BEDFORD CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MILLS MANOR NURSING HOME | ||||||||
| 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: | 500 BECK LN | ||||||||
| Address2: | |||||||||
| City: | MAYFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420661950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702477890 | ||||||||
| FaxNumber: | 2702513689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 02/05/2008 | ||||||||
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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 | 313M00000X | 100472 | KY | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 100472 | KY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 12504098 | 05 | KY | MEDICAID | 90003963 | 05 | KY | MEDICAID |