MEDICARE: BAYSIDE RECOVERY AND WELLNESS CENTER LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	261QM0850X	Adult Mental Health Clinic/Center
3	261QR0400X	Rehabilitation Clinic/Center
4	324500000X	Substance Abuse Rehabilitation Facility
5	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1134775976
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYSIDE RECOVERY AND WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	1501 ROBERT J CONLAN BLVD NE STE 7
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-3559
Country	:	US
Telephone Number	:	321-372-6897
Fax Number	:	321-372-6896

Provider Business Practice Location Address
First Line	:	1501 ROBERT J CONLAN BLVD NE STE 7
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-3559
Country	:	US
Telephone Number	:	321-372-6897
Fax Number	:	321-372-6896

Authorized Official
Title or Position	:	CEO/CLINCIAL DIRECTOR
Name	:	MORGAN O'SHAUGHNESSY
Credential	:	LMHC
Telephone Number	:	321-372-6897

Provider Enumeration Date	:	08/16/2019
Last Update Date	:	12/13/2021

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