MEDICARE: BAYOU SHORES SNF LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063766707
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYOU SHORES SNF LLC

Provider Business Mailing Address
First Line	:	1835 NE MIAMI GARDENS DR # 368
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33179-5035
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	435 42ND AVE S
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33705-4504
Country	:	US
Telephone Number	:	727-822-1871
Fax Number	:	727-894-0836

Authorized Official
Title or Position	:	AUTHORIZED MEMBER
Name	:	MR. TZVI BOGOMILSKY
Credential	:
Telephone Number	:	305-403-1400

Provider Enumeration Date	:	11/02/2012
Last Update Date	:	11/02/2012

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