MEDICARE: EAST BAY NC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	SNF11340962	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V516P-6822	OTHER		VA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598752180
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST BAY NC, LLC

Provider Business Mailing Address
First Line	:	4470 E BAY DR
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33764-5772
Country	:	US
Telephone Number	:	727-530-7100
Fax Number	:	727-539-8024

Provider Business Practice Location Address
First Line	:	4470 E BAY DR
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33764-5772
Country	:	US
Telephone Number	:	727-530-7100
Fax Number	:	727-539-8024

Authorized Official
Title or Position	:	AS SOLE MEMBER OF SBK CAPITAL LLC
Name	:	MR. SAMUEL B KELLETT
Credential	:
Telephone Number	:	404-233-7048

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	01/30/2009

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