Provider Demographics
NPI:1982091476
Name:GULF SHORE FACILITY INC
Entity Type:Organization
Organization Name:GULF SHORE FACILITY INC
Other - Org Name:GULF SHORE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-641-8314
Mailing Address - Street 1:4302 HOLLYWOOD BLVD
Mailing Address - Street 2:#369
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6767 86TH AVENURE NORTH
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33782-4597
Practice Address - Country:US
Practice Address - Phone:727-584-5566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF130470981314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105978Medicare Oscar/Certification