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General NPI Number Information
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NPI Number | 1740404870
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Entity Type | Organization
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Legal Business Name | BEACH CLUB RESIDENTIAL LIVING INC
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5254 LAKE RD E SUITE #3
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City | GENEVA
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State | OH
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Zip | 44041-9490
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Country | US
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Telephone | 440-466-0988
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Fax | 440-466-0315
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Provider Business Mailing Address
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Address Line | 5254 LAKE RD E SUITE #3
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City | GENEVA
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State | OH
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Zip | 44041-9490
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Country | US
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Telephone | 440-466-0988
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Fax | 440-466-0315
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Authorized Official
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Title or Position | OWNER
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Name | MRS. LUANN KAY BUSCH
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Credential |
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Telephone | 440-466-0988
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 2056975
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License Number State | OH
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