Healthcare Provider Details

I. General information

NPI: 1356835862
Provider Name (Legal Business Name): BAY AREA DIRECT CLIENT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LITHIA PINECREST RD STE B
BRANDON FL
33511-5300
US

IV. Provider business mailing address

2105 ROANOKE SPRINGS DR
RUSKIN FL
33570-6312
US

V. Phone/Fax

Practice location:
  • Phone: 813-679-5122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0001X
TaxonomyClinical & Laboratory Immunology (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: DESHAE MARTIN
Title or Position: ADMINISTRATIVE DIRECTOR
Credential: NURSE PRACTITIONER
Phone: 813-585-7708