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General NPI Number Information
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NPI Number | 1063766707
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Entity Type | Organization
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Legal Business Name | BAYOU SHORES SNF LLC
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Dates
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Enumeration Date | 11/02/2012
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Last Update Date | 11/02/2012
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Provider Practice Location Address
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Address Line | 435 42ND AVE S
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City | SAINT PETERSBURG
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State | FL
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Zip | 33705-4504
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Country | US
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Telephone | 727-822-1871
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Fax | 727-894-0836
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Provider Business Mailing Address
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Address Line | 1835 NE MIAMI GARDENS DR # 368
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City | NORTH MIAMI BEACH
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State | FL
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Zip | 33179-5035
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED MEMBER
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Name | MR. TZVI BOGOMILSKY
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Credential |
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Telephone | 305-403-1400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number |
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License Number State |
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