Provider Demographics
NPI:1376981985
Name:BEACHLAND RETIREMENT HOME
Entity Type:Organization
Organization Name:BEACHLAND RETIREMENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GROCHOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-460-8007
Mailing Address - Street 1:462 HERNANDO ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34949-3243
Mailing Address - Country:US
Mailing Address - Phone:772-460-8007
Mailing Address - Fax:772-460-8007
Practice Address - Street 1:462 HERNANDO ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34949-3243
Practice Address - Country:US
Practice Address - Phone:772-460-8007
Practice Address - Fax:772-460-8007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8841261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL675980700Medicaid