1598752180 NPI number — EAST BAY NC, LLC

Table of content: (NPI 1598752180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598752180 NPI number — EAST BAY NC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST BAY NC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EAST BAY REHABILITATION CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598752180
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4470 E BAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33764-5772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-530-7100
Provider Business Mailing Address Fax Number:
727-539-8024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4470 E BAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEARWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33764-5772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-530-7100
Provider Business Practice Location Address Fax Number:
727-539-8024
Provider Enumeration Date:
09/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KELLETT
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
AS SOLE MEMBER OF SBK CAPITAL LLC
Authorized Official Telephone Number:
404-233-7048

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  SNF11340962 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: V516P-6822 . This is a "VA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 026453900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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