Healthcare Provider Details

I. General information

NPI: 1295991107
Provider Name (Legal Business Name): TAY GAINES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 09/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4152 BLUE HERON BLVD W SUITE 123
RIVIERA BEACH FL
33404-4811
US

IV. Provider business mailing address

4152 BLUE HERON BLVD W SUITE 123
RIVIERA BEACH FL
33404-4811
US

V. Phone/Fax

Practice location:
  • Phone: 561-844-7699
  • Fax: 561-842-8215
Mailing address:
  • Phone: 561-844-7699
  • Fax: 561-842-8215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberME55707
License Number StateFL

VIII. Authorized Official

Name: DR. TAY GARNETT GAINES
Title or Position: PRESIDENT/MEMBER
Credential: M.D.
Phone: 561-844-7699