Provider Demographics
NPI:1962024539
Name:BEACHES BAR & CAFE
Entity type:Organization
Organization Name:BEACHES BAR & CAFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:MS
Authorized Official - First Name:AYANNA
Authorized Official - Middle Name:BABCOCK
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PCT
Authorized Official - Phone:561-294-5711
Mailing Address - Street 1:4597 ARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-5733
Mailing Address - Country:US
Mailing Address - Phone:561-294-7741
Mailing Address - Fax:561-294-7741
Practice Address - Street 1:840 US HIGHWAY 1 STE 435C
Practice Address - Street 2:
Practice Address - City:N PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-3829
Practice Address - Country:US
Practice Address - Phone:561-294-7741
Practice Address - Fax:561-805-1097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335G00000XSuppliersMedical Foods Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0108130000Medicaid