Provider Demographics
NPI:1366771214
Name:BAYSIDE INJURY CENTER LLC
Entity type:Organization
Organization Name:BAYSIDE INJURY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAMANTIDES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-374-0128
Mailing Address - Street 1:2901 W BUSCH BLVD
Mailing Address - Street 2:SUITE 1018
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-4523
Mailing Address - Country:US
Mailing Address - Phone:813-374-0128
Mailing Address - Fax:813-374-0181
Practice Address - Street 1:2901 W BUSCH BLVD
Practice Address - Street 2:SUITE 1018
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-4523
Practice Address - Country:US
Practice Address - Phone:813-374-0128
Practice Address - Fax:813-374-0181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service