=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992958185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BELLE VISTA RETIREMENT HOME, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2008
-----------------------------------------------------
Last Update Date | 10/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1453 BELLEAIR RD
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33756-2356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-587-0880
-----------------------------------------------------
Fax | 727-588-2397
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1453 BELLEAIR RD
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33756-2356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-587-0880
-----------------------------------------------------
Fax | 727-588-2397
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | BEVERLY C. MACKIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-587-0880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL7261
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------