Provider Demographics
NPI:1790038776
Name:SEASIDE MANOR, LLC
Entity Type:Organization
Organization Name:SEASIDE MANOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:I
Authorized Official - Last Name:WEISBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-292-5706
Mailing Address - Street 1:26691 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44146-1421
Mailing Address - Country:US
Mailing Address - Phone:216-292-5706
Mailing Address - Fax:216-292-2273
Practice Address - Street 1:1050 OCEAN SHORE BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32176-4126
Practice Address - Country:US
Practice Address - Phone:386-441-1771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SABER HEALTHCARE HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-16
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8860310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008052000Medicaid