Provider Demographics
NPI:1700047974
Name:BAYAMO ASSISTED LIVING
Entity Type:Organization
Organization Name:BAYAMO ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LORNA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-873-2903
Mailing Address - Street 1:1199 SW BAYAMO AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1852
Mailing Address - Country:US
Mailing Address - Phone:772-873-2903
Mailing Address - Fax:772-873-0085
Practice Address - Street 1:1199 SW BAYAMO AVE
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-1852
Practice Address - Country:US
Practice Address - Phone:772-873-2903
Practice Address - Fax:772-873-0085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10726310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6913636 00.Medicaid