=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124090113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYSHORE NURSING & REHAB CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1661 W YOAKUM AVE
-----------------------------------------------------
City | ARANSAS PASS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78336-4431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-758-7686
-----------------------------------------------------
Fax | 361-758-3545
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 155635
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76155-0635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-359-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | GARY R TREBERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-359-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------