Provider Demographics
NPI:1487941399
Name:BEACON BY THE BAY LLC
Entity type:Organization
Organization Name:BEACON BY THE BAY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROJAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-647-4000
Mailing Address - Street 1:141 KAELYN LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-6180
Mailing Address - Country:US
Mailing Address - Phone:850-647-4000
Mailing Address - Fax:850-647-4004
Practice Address - Street 1:141 KAELYN LN
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-6180
Practice Address - Country:US
Practice Address - Phone:850-647-4000
Practice Address - Fax:850-647-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10713310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000451700Medicaid