Healthcare Provider Details

I. General information

NPI: 1649720343
Provider Name (Legal Business Name): BAYVUE ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2506 LITHIA PINECREST RD
VALRICO FL
33596-5036
US

IV. Provider business mailing address

3433 LITHIA PINECREST RD STE 135
VALRICO FL
33596-6302
US

V. Phone/Fax

Practice location:
  • Phone: 813-436-0735
  • Fax: 813-436-0735
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL12895
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: TENNILLE JOPLIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 813-391-8398