Provider Demographics
NPI:1740404870
Name:BEACH CLUB RESIDENTIAL LIVING INC
Entity Type:Organization
Organization Name:BEACH CLUB RESIDENTIAL LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUANN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-466-0988
Mailing Address - Street 1:5254 LAKE RD E
Mailing Address - Street 2:SUITE #3
Mailing Address - City:GENEVA
Mailing Address - State:OH
Mailing Address - Zip Code:44041-9490
Mailing Address - Country:US
Mailing Address - Phone:440-466-0988
Mailing Address - Fax:440-466-0315
Practice Address - Street 1:5254 LAKE RD E
Practice Address - Street 2:SUITE #3
Practice Address - City:GENEVA
Practice Address - State:OH
Practice Address - Zip Code:44041-9490
Practice Address - Country:US
Practice Address - Phone:440-466-0988
Practice Address - Fax:440-466-0315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2056975320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0400355OtherCONTRACT NUMBER
OH2056975Medicaid