Provider Demographics
NPI:1134366529
Name:BAYSHORE HEALTHCARE, INC.
Entity type:Organization
Organization Name:BAYSHORE HEALTHCARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MS
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:3033 AUGUSTA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-5820
Mailing Address - Country:US
Mailing Address - Phone:805-544-5100
Mailing Address - Fax:805-544-7209
Practice Address - Street 1:3033 AUGUSTA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-5820
Practice Address - Country:US
Practice Address - Phone:805-544-5100
Practice Address - Fax:805-544-7209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA050000083314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA056189Medicare Oscar/Certification