Provider Demographics
NPI:1164527388
Name:BAYROAD ENTERPRISES INC DBA
Entity Type:Organization
Organization Name:BAYROAD ENTERPRISES INC DBA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:MOFFETT
Authorized Official - Last Name:TONKIN
Authorized Official - Suffix:III
Authorized Official - Credentials:CP, LP
Authorized Official - Phone:904-213-4430
Mailing Address - Street 1:PO BOX 1657
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32067-1657
Mailing Address - Country:US
Mailing Address - Phone:904-213-4430
Mailing Address - Fax:904-276-7823
Practice Address - Street 1:617 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5058
Practice Address - Country:US
Practice Address - Phone:904-213-4430
Practice Address - Fax:904-276-7823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0663660001Medicare ID - Type Unspecified
FL0663660003Medicare ID - Type Unspecified
FL0663660002Medicare ID - Type Unspecified