Basic Information
| Provider Information | |||||||||
| NPI: | 1912646597 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEDROCK HCS AT W BRADLEY RD WI OPCO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 OBERLIN AVE N STE 6 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087014535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328006005 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6735 W BRADLEY RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532233325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143543300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2022 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | KOHLS | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4147506987 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.