MEDICARE: BEACH BAY AND TACKLE LLC DBA HOME CARE PROVIDER SERVICE

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	253Z00000X	In Home Supportive Care Agency	149211	TX

General Provider Information

NPI Number	:	1992197412
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACH BAY AND TACKLE LLC DBA HOME CARE PROVIDER SERVICE

Provider Business Mailing Address
First Line	:	3780 MARTIN LUTHER KING JR DR
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77640-6862
Country	:	US
Telephone Number	:	409-782-0332
Fax Number	:	409-300-4389

Provider Business Practice Location Address
First Line	:	3780 MARTIN LUTHER KING JR DR
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77640-6862
Country	:	US
Telephone Number	:	409-782-0332
Fax Number	:	409-300-4389

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL RYAN ZUMWALT
Credential	:	LVN
Telephone Number	:	409-782-0332

Provider Enumeration Date	:	02/20/2015
Last Update Date	:	02/20/2015

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