Healthcare Provider Details

I. General information

NPI: 1982991121
Provider Name (Legal Business Name): BAYSHORE RETREAT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

457 CAHOUN AVE
DESTIN FL
32541
US

IV. Provider business mailing address

PO BOX 365
DESTIN FL
32540-0365
US

V. Phone/Fax

Practice location:
  • Phone: 850-269-3975
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number0146AD1561-01
License Number StateFL

VIII. Authorized Official

Name: JEFFREY JENKS
Title or Position: COO
Credential:
Phone: 850-269-3975