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General NPI Number Information
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NPI Number | 1649797242
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Entity Type | Organization
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Legal Business Name | BEACHSIDE LIVING LLC
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Dates
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Enumeration Date | 08/24/2017
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Last Update Date | 08/24/2017
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Provider Practice Location Address
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Address Line | 420 N RIVERSIDE DR
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City | POMPANO BEACH
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State | FL
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Zip | 33062-5035
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Country | US
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Telephone | 954-788-8350
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Fax |
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Provider Business Mailing Address
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Address Line | 111 N POMPANO BEACH BLVD APT 1104
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City | POMPANO BEACH
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State | FL
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Zip | 33062-5716
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Country | US
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Telephone | 908-240-5854
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | VADIM MEZRIN
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Credential |
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Telephone | 908-240-5854
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number | 10156
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License Number State | FL
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