=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669697942
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYSIDE HOSPICE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 08/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25636 NARBONNE AVE SUITE C
-----------------------------------------------------
City | LOMITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90717-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-891-3500
-----------------------------------------------------
Fax | 310-891-1333
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25636 NARBONNE AVE SUITE C
-----------------------------------------------------
City | LOMITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90717-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-891-3500
-----------------------------------------------------
Fax | 310-891-1333
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ERWIN D REYES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-891-3500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------