Provider Demographics
NPI:1912029521
Name:BAYSIDE TERRACE LLC
Entity Type:Organization
Organization Name:BAYSIDE TERRACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEMETRIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:RAFAEL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:847-244-8196
Mailing Address - Street 1:1100 S LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-7710
Mailing Address - Country:US
Mailing Address - Phone:847-244-8196
Mailing Address - Fax:
Practice Address - Street 1:1100 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-7710
Practice Address - Country:US
Practice Address - Phone:847-244-8196
Practice Address - Fax:847-244-7647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0023036310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness