Provider Demographics
NPI:1578739637
Name:BAYBREEZE
Entity Type:Organization
Organization Name:BAYBREEZE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADULT CARETAKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TESS
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLONG
Authorized Official - Suffix:
Authorized Official - Credentials:AD
Authorized Official - Phone:562-432-8033
Mailing Address - Street 1:1653 SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-1240
Mailing Address - Country:US
Mailing Address - Phone:562-432-8033
Mailing Address - Fax:
Practice Address - Street 1:1653 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-1240
Practice Address - Country:US
Practice Address - Phone:562-432-8033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA191600093323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility