Provider Demographics
NPI:1598752180
Name:EAST BAY NC, LLC
Entity Type:Organization
Organization Name:EAST BAY NC, LLC
Other - Org Name:EAST BAY REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AS SOLE MEMBER OF SBK CAPITAL LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:KELLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-233-7048
Mailing Address - Street 1:4470 E BAY DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-5772
Mailing Address - Country:US
Mailing Address - Phone:727-530-7100
Mailing Address - Fax:727-539-8024
Practice Address - Street 1:4470 E BAY DR
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-5772
Practice Address - Country:US
Practice Address - Phone:727-530-7100
Practice Address - Fax:727-539-8024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF11340962314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
V516P-6822OtherVA
FL026453900Medicaid
FL026453900Medicaid