Healthcare Provider Details

I. General information

NPI: 1700565678
Provider Name (Legal Business Name): BEACHSIDE OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 02/08/2024
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 S ATLANTIC AVE
NEW SMYRNA BEACH FL
32169-3446
US

IV. Provider business mailing address

2901 STIRLING RD STE 200
FORT LAUDERDALE FL
33312-6529
US

V. Phone/Fax

Practice location:
  • Phone: 954-300-3878
  • Fax:
Mailing address:
  • Phone: 954-300-3878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JACOB BENGIO
Title or Position: CFO
Credential:
Phone: 305-562-5501