Provider Demographics
NPI:1891748638
Name:BAYSIDE REHABILITATION
Entity type:Organization
Organization Name:BAYSIDE REHABILITATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:STONESTREET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-442-5222
Mailing Address - Street 1:PO BOX 149
Mailing Address - Street 2:
Mailing Address - City:BELLE HAVEN
Mailing Address - State:VA
Mailing Address - Zip Code:23306-0149
Mailing Address - Country:US
Mailing Address - Phone:757-442-5222
Mailing Address - Fax:
Practice Address - Street 1:15405 MERRY CAT LANE
Practice Address - Street 2:
Practice Address - City:BELLE HAVEN
Practice Address - State:VA
Practice Address - Zip Code:23306
Practice Address - Country:US
Practice Address - Phone:757-442-5222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204132261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09802Medicare UPIN