Basic Information
| Provider Information | |||||||||
| NPI: | 1588830020 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMPASS HEALTH INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BAYSIDE CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 S 13TH ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | GROVER BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934332263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054747010 | ||||||||
| FaxNumber: | 8054738766 | ||||||||
| Practice Location | |||||||||
| Address1: | 1405 TERESA DR | ||||||||
| Address2: | |||||||||
| City: | MORRO BAY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934422458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057722237 | ||||||||
| FaxNumber: | 8057722536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2008 | ||||||||
| LastUpdateDate: | 05/17/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOYA | ||||||||
| AuthorizedOfficialFirstName: | MARIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 8054747010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMPASS HEALTH INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 050000043 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | LTC90045G | 05 | CA | MEDICAID |