Provider Demographics
NPI:1003584301
Name:BAY AREA DIRECT CLIENT CARE LLC
Entity Type:Organization
Organization Name:BAY AREA DIRECT CLIENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DESHAE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:813-679-5122
Mailing Address - Street 1:2105 ROANOKE SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-6312
Mailing Address - Country:US
Mailing Address - Phone:813-679-5122
Mailing Address - Fax:564-524-5855
Practice Address - Street 1:110 LITHIA PINECREST RD STE B
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5300
Practice Address - Country:US
Practice Address - Phone:813-679-5122
Practice Address - Fax:564-524-5855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-01
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112087100Medicaid