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General NPI Number Information
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NPI Number | 1982991121
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Entity Type | Organization
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Legal Business Name | BAYSHORE RETREAT, LLC
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Dates
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Enumeration Date | 07/08/2011
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Last Update Date | 07/08/2011
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Provider Practice Location Address
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Address Line | 457 CAHOUN AVE
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City | DESTIN
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State | FL
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Zip | 32541
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Country | US
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Telephone | 850-269-3975
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 365
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City | DESTIN
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State | FL
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Zip | 32540-0365
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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 | COO
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Name | JEFFREY JENKS
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Credential |
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Telephone | 850-269-3975
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 0146AD1561-01
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License Number State | FL
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