Provider Demographics
NPI:1497922538
Name:BAYSHORE RESIDENCE ALF
Entity Type:Organization
Organization Name:BAYSHORE RESIDENCE ALF
Other - Org Name:ASSISTED LIVING FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VIOLET
Authorized Official - Middle Name:VERONA
Authorized Official - Last Name:BURKE7728711106
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-871-1106
Mailing Address - Street 1:686 SW LUCERO DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1894
Mailing Address - Country:US
Mailing Address - Phone:772-871-1106
Mailing Address - Fax:772-871-1104
Practice Address - Street 1:686 SW LUCERO DR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1894
Practice Address - Country:US
Practice Address - Phone:772-871-1106
Practice Address - Fax:772-871-1104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL750261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care