Provider Demographics
NPI:1992197412
Name:BEACH BAY AND TACKLE LLC DBA HOME CARE PROVIDER SERVICE
Entity Type:Organization
Organization Name:BEACH BAY AND TACKLE LLC DBA HOME CARE PROVIDER SERVICE
Other - Org Name:HOME CARE PROVIDER SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:ZUMWALT
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:409-782-0332
Mailing Address - Street 1:3780 MARTIN LUTHER KING JR DR
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640-6862
Mailing Address - Country:US
Mailing Address - Phone:409-782-0332
Mailing Address - Fax:409-300-4389
Practice Address - Street 1:3780 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-6862
Practice Address - Country:US
Practice Address - Phone:409-782-0332
Practice Address - Fax:409-300-4389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX149211253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care