Provider Demographics
NPI:1033451380
Name:CRESCENT BEACH CARE, LLC
Entity Type:Organization
Organization Name:CRESCENT BEACH CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER-MANAGED
Authorized Official - Prefix:DR
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-342-7363
Mailing Address - Street 1:6573 A1A S
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-7504
Mailing Address - Country:US
Mailing Address - Phone:904-342-7363
Mailing Address - Fax:904-342-7367
Practice Address - Street 1:6573 A1A S
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-7504
Practice Address - Country:US
Practice Address - Phone:904-342-7363
Practice Address - Fax:904-342-7367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-25
Last Update Date:2013-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109167261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care