Provider Demographics
NPI:1356835862
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:NURSE PRACTITIONER
Authorized Official - Phone:813-585-7708
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:
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-18
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RI0001X, 251E00000X, 251J00000X, 313M00000X, 320900000X, 385HR2060X
FL373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory ImmunologyGroup - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Single Specialty
No251J00000XAgenciesNursing CareGroup - Single Specialty
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care FacilityGroup - Single Specialty
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Single Specialty
No373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, ChildGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNONEOtherNONE ASSOCIATED
FL025147900Medicaid