MEDICARE: BAY OAKS HISTORIC RETIREMENT RESIDENCE

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	310400000X	Assisted Living Facility	AL5168	FL

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	:	1497170195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAY OAKS HISTORIC RETIREMENT RESIDENCE

Provider Business Mailing Address
First Line	:	435 NE 34TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33137-4012
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	435 NE 34TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33137-4012
Country	:	US
Telephone Number	:	305-573-4337
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KATHRYN KASSNER
Credential	:
Telephone Number	:	305-573-4337

Provider Enumeration Date	:	03/04/2014
Last Update Date	:	02/03/2017

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