Healthcare Provider Details

I. General information

NPI: 1497922538
Provider Name (Legal Business Name): BAYSHORE RESIDENCE ALF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

686 SW LUCERO DR
PORT SAINT LUCIE FL
34983-1894
US

IV. Provider business mailing address

686 SW LUCERO DR
PORT SAINT LUCIE FL
34983-1894
US

V. Phone/Fax

Practice location:
  • Phone: 772-871-1106
  • Fax: 772-871-1104
Mailing address:
  • Phone: 772-871-1106
  • Fax: 772-871-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberAL750
License Number StateFL

VIII. Authorized Official

Name: MS. VIOLET VERONA BURKE7728711106
Title or Position: ADMINISTRATOR
Credential:
Phone: 772-871-1106