Provider Demographics
NPI:1124656202
Name:BEDROCK HCS AT DAYTONA FL LLC
Entity type:Organization
Organization Name:BEDROCK HCS AT DAYTONA FL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-328-7499
Mailing Address - Street 1:792 VINE AVE BSMT
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5340
Mailing Address - Country:US
Mailing Address - Phone:347-598-1029
Mailing Address - Fax:
Practice Address - Street 1:595 N WILLIAMSON BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-7185
Practice Address - Country:US
Practice Address - Phone:732-328-7499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-01
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility