Basic Information
| Provider Information | |||||||||
| NPI: | 1184230906 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEACH HOUSE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2283 ASHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436201205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192442175 | ||||||||
| FaxNumber: | 4192442253 | ||||||||
| Practice Location | |||||||||
| Address1: | 2283 ASHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436201205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192442175 | ||||||||
| FaxNumber: | 4192442253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2020 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | GLYDA | ||||||||
| AuthorizedOfficialFirstName: | ANGELIQUE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4193800116 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.