Healthcare Provider Details

I. General information

NPI: 1639367287
Provider Name (Legal Business Name): LA BAHIA ADULT DAY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 N JEFFERSON ST
GOLIAD TX
77963-4022
US

IV. Provider business mailing address

446 N JEFFERSON ST
GOLIAD TX
77963-4022
US

V. Phone/Fax

Practice location:
  • Phone: 361-645-8797
  • Fax: 361-645-4019
Mailing address:
  • Phone: 361-645-8797
  • Fax: 361-645-4019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number120217
License Number StateTX

VIII. Authorized Official

Name: MS. SUZANNE PENDERGRAPH
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 361-645-8797