Healthcare Provider Details

I. General information

NPI: 1205681509
Provider Name (Legal Business Name): BAYSHORE HAND REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2024
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 COPPER RIDGE DR STE 204D
TRAVERSE CITY MI
49684-6721
US

IV. Provider business mailing address

428 W 8TH ST
TRAVERSE CITY MI
49684-3105
US

V. Phone/Fax

Practice location:
  • Phone: 231-300-8411
  • Fax:
Mailing address:
  • Phone: 760-712-9309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: NICHOLE ROOST
Title or Position: OTRL, CHT, OWNER
Credential: OTRL, CHT
Phone: 760-712-9309