1255281028 NPI number — SHORE SIDE BEHAVIORAL HEALTH SERVICE, LLC

Table of content: (NPI 1255281028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255281028 NPI number — SHORE SIDE BEHAVIORAL HEALTH SERVICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHORE SIDE BEHAVIORAL HEALTH SERVICE, 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:
Provider Other Organization Name Type Code:
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:
1255281028
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH SHORE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41175-0204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-498-4367
Provider Business Mailing Address Fax Number:
606-826-1780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 E 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH SHORE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41175-8927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-498-4367
Provider Business Practice Location Address Fax Number:
606-826-1780
Provider Enumeration Date:
02/02/2026

Additional Information

Authorized Official

Authorized Official Last Name:
BENTLEY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
BRYANT
Authorized Official Title or Position:
OWNER, CHIEF CLINICIAN
Authorized Official Telephone Number:
606-498-4367

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2026 www.npivalidator.com