Basic Information
| Provider Information | |||||||||
| NPI: | 1932156296 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEVERLY HEALTH AND REHABILITIATION SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BEVERLY LIVINGCENTER - BRADLEY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6735 W BRADLEY RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532233325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143543300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6735 W BRADLEY RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532233325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143543300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MERRELL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4792014840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20-1098-00 | 05 | WI | MEDICAID | 525325 | 01 | WI | SECURITY HP | OTHER |