MEDICARE: FOOTPRINTS BEACHSIDE RECOVERY INC

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center		FL

General Provider Information

NPI Number	:	1487002457
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOTPRINTS BEACHSIDE RECOVERY INC

Provider Business Mailing Address
First Line	:	151 107TH AVE
Second Line	:	SUITE 13
City	:	TREASURE ISLAND
State	:	FL
Zip	:	33706-4734
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	151 107TH AVE
Second Line	:	SUITE 13
City	:	TREASURE ISLAND
State	:	FL
Zip	:	33706-4734
Country	:	US
Telephone Number	:	727-954-3908
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	NICOLA RAJARAM
Credential	:
Telephone Number	:	954-272-6723

Provider Enumeration Date	:	05/31/2016
Last Update Date	:	05/31/2016

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