Provider Demographics
NPI:1164863379
Name:BAIM OF GILEAD HEALTHCARE SERVICES INC.
Entity Type:Organization
Organization Name:BAIM OF GILEAD HEALTHCARE SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:DEMETRUIS
Authorized Official - Last Name:ROQUEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MOML,CAP,CCJAP
Authorized Official - Phone:813-443-5028
Mailing Address - Street 1:9804 N 26TH STREET
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612
Mailing Address - Country:US
Mailing Address - Phone:813-443-5028
Mailing Address - Fax:
Practice Address - Street 1:9804 N 26TH ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-8420
Practice Address - Country:US
Practice Address - Phone:813-443-5028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health