52D2175793 CLIA NUMBER - BEAVER DAM AL OPERATIONS, LLC DBA CHARLESTON HOUSE AL

Laboratory Demographics

CLIA Number: 52D2175793

Facility Name: BEAVER DAM AL OPERATIONS, LLC DBA CHARLESTON HOUSE AL

Facility Address:
104 FAKES CT
BEAVER DAM, WI
ZIP 53916
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Facility Phone Number: 763 670-9077

Facility Type: Assisted Living Facility

Certificate Type: Waiver

NPI Number: 1265090559

Taxonomy: 310400000X - Assisted Living Facility
A facility providing supportive services to individuals who can function independently in most areas of activity, but need assistance and/or monitoring to assure safety and well being.

CLIA Record

Field Name	Field Value
CLIA Number	52D2175793
LAB Type	Assisted Living Facility
Facility Name	BEAVER DAM AL OPERATIONS, LLC DBA CHARLESTON HOUSE AL
Street	104 FAKES CT
City	BEAVER DAM
State	WI
ZIP	53916
Phone	763 670-9077
CertificateType	4
CertificateEffectiveDate	12/2/2023
CertificateExpirationDate	12/1/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024