MEDICARE: GULF SHORE FACILITY 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	314000000X	Skilled Nursing Facility	SNF130470981	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	:	1982091476
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GULF SHORE FACILITY INC

Provider Business Mailing Address
First Line	:	4302 HOLLYWOOD BLVD
Second Line	:	#369
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-6635
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6767 86TH AVENURE NORTH
Second Line	:
City	:	PINELLAS PARK
State	:	FL
Zip	:	33782-4597
Country	:	US
Telephone Number	:	727-584-5566
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	MR. MICHAEL BLEICH
Credential	:
Telephone Number	:	845-641-8314

Provider Enumeration Date	:	04/22/2015
Last Update Date	:	04/29/2015

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