MEDICARE: BEACH CLUB RESIDENTIAL LIVING 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	2056975	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0400355	OTHER	OH	CONTRACT NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740404870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACH CLUB RESIDENTIAL LIVING INC

Provider Business Mailing Address
First Line	:	5254 LAKE RD E
Second Line	:	SUITE #3
City	:	GENEVA
State	:	OH
Zip	:	44041-9490
Country	:	US
Telephone Number	:	440-466-0988
Fax Number	:	440-466-0315

Provider Business Practice Location Address
First Line	:	5254 LAKE RD E
Second Line	:	SUITE #3
City	:	GENEVA
State	:	OH
Zip	:	44041-9490
Country	:	US
Telephone Number	:	440-466-0988
Fax Number	:	440-466-0315

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. LUANN KAY BUSCH
Credential	:
Telephone Number	:	440-466-0988

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	08/22/2020

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